CLINICAL ARTICLE
Role of cosmeceutical skincare
in the management of acne
There is a growing body of evidence showing the benefit of some common cosmeceutical agents
in the various pathogenic stages of acne. Sarah Boxley explains why an understanding of the roles
of these products, the evidence to support their use, and their potential side effects, should enable
practitioners to effectively and appropriately advise patients on their benefits and limitations
A
cne vulgaris is a common chronic inflammatory
disease of varying severity (Zaenglein et al, 2016),
which frequently requires long-term management.
An epidemiological study published in 2013 revealed
that acne affects up to 85% of adolescents and can persist into
adulthood, affecting 64% of adults in their 20s and 43% of adults
in their 30s (Bhate and Williams, 2013).
Although clinical guidelines on acne are well-established
(Archer et al, 2012; Nast et al, 2016; Zaenglein et al, 2016), the
use and efficacy of physiologically active cosmetics, otherwise
known as ‘cosmeceuticals’ or ‘dermocosmetics’, are less well-
known. Traditional cosmetics are powders or creams designed
to enhance a person’s appearance following direct application
onto the skin. The term ‘cosmeceutical’ was coined by a founding
member of the US Society of Cosmetic Chemists, Raymond Reed,
in 1961 (Newburger, 2009), and subsequently made popular by
Albert Kligman, who used the term in 1984 to describe products
that do ‘more than colouring the skin and less than a therapeutic
drug’ (Barros and Zaenglein, 2017).
Over recent years, scientific and technological developments
have changed clinicians’ understanding of the physiology
of normal skin, and how cosmeceutical agents can alter its
appearance through physical modification and biological
activity (Newburger, 2009). Dermocosmetics is now a branch of
dermatology in the scientific management of a variety of skin
disorders, including acne.
Cosmeceuticals are intermediate products between
prescription medications and cosmetics. They are growing in
number and popularity, and may provide another management
strategy for long-term disease and during periods of relapse
(Dreno et al, 2014). Products are available for direct purchase by
consumers without a medical prescription, and this multibillion
dollar industry is not subject to regulation by the US Food and
Drug Administration or other similar legislative bodies around
the world (Barros and Zaenglein, 2017).
SARAH BOXLEY
Cosmetic Physician, The Skin Clinic Fremantle,
Western Australia.
e: drsarah@skinclinicfremantle.com.au
8
Most consumers mistakenly believe that not only are
cosmeceuticals regulated and tested as drugs, but also that
the ingredients and final products have been tested for safety
and the claims made in advertisements are valid (Newburger,
2009). Despite the fact that the regulatory environments
of cosmeceuticals and pharmaceuticals are vastly different,
published data from trials of cosmeceutical products in human
subjects are available and can be assessed, in addition to
traditional in vitro and in vivo techniques and research, using a
range of modern non-invasive methods, such as image analysis
and biometric testing (Barros and Zaenglein, 2017).
Aesthetic practitioners may often be in a position where they
are asked to recommend skincare regimens for patients with
acneic skin. Having an understanding of the roles of the various
cosmeceutical agents in the management of acne, as well as the
evidence for their use and their potential side effects, should
enable aesthetic practitioners to effectively and appropriately
advise patients on the benefits and limitations of these products.
Pathogenic pathways of acne
Acne vulgaris is a multifactorial disease originating in the
pilosebaceous unit of the skin. The pathogenesis of acne
comprises four main pathways (Suh and Kwon, 2015):
►► Release of inflammatory mediators into the skin
►► Abnormal keratinisation with hypercornification of the
pilosebaceous duct
►► Excess sebum (oil) production
►► Colonisation by the bacteria Propionibacterium acnes (P. acnes).
A number of cosmeceutical agents have been shown to exert
influence on one or more of these pathways (Table 1). Those
with the most substantial evidence base are discussed in more
detail below.
Retinoids
Topical vitamin A derivatives target a number of pathogenic
factors and are the mainstay of cosmeceutical acne therapy.
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Topical retinoids have been shown to modulate epithelial
turnover, therefore having a comeolytic effect (Araviiskaia
and Dréno, 2016). They have also been found to alter various
transcription factors involved in cascades of skin inflammation,
and to inhibit the inflammatory response to P. acnes (Del Rosso,
2013; Agak et al, 2014).
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 Table 1: Pathogenic pathways of acne unlike niacin, is readily absorbed through the skin (Barros and
and corresponding cosmeceutical agents Zaenglein, 2017) and, depending on its concentration, has been
with evidence of action shown to have antipruritic, antimicrobial, anti-inflammatory,
vasoactive, photoprotective, sebostatic and lightening effects
Pathogenic pathway Cosmeceutical agent
(Wohlrab and Kreft, 2014).
Abnormal sebum Niacinamide
Topical niacinamide increases desquamation and
production Fullerene
Epigallocatechin-3-gallate (a polyphenol reduces sebum production in a dose-dependent manner
found in green tea) (Araviiskaia and Dréno, 2016). In two double-blind placebo-
Sodium L-ascorbyl-2-phosphate controlled studies involving Japanese and Caucasian subjects,
(antioxidant derived from vitamin C)
topical 2% niacinamide was shown to reduce the rate of sebum
Abnormal keratinisation Alpha hydroxy acids (e.g. glycolic acid, excretion in the Japanese patients, while reducing the casual
lactic acid)
sebum levels, but not the sebum excretion rates, in the Caucasian
Salicylic acid
Lipohydroxy acid group (Draelos et al, 2006).
Retinoids A prospective, double-blind, randomised, multicentre study
Linoleic acid (omega-6) of  76 patients with moderate inflammatory acne (defined
Propionibacterium acnes Lauric acid as 15 or more papules or pustules) compared the efficacy of
colonisation Zinc salts niacinamide  4%  and clindamycin 1% gels (Shalita et al, 1995).
Oat plantlet extract
Both preparations reduced acne severity and acne lesion
Inflammation Niacinamide counts, while showing improvement in the Physician Global
Retinoids
Salicylic acid Evaluation of Inflammatory Acne. These measures trended
Alpha-linolenic acid (omega-3) towards niacinamide being more efficacious, although statistical
Zinc salts significance was not reached. A statistically significant decrease in
Oat plantlet extract the number of pustules, comedones and papules was found when
Green et al (2009); Araviiskaia and Dréno (2016); Barros and Zaenglein (2017) 4% niacinamide gel was applied topically for 8 weeks in 41 patients
with mild-to-moderate acne (Kaymak and Önder, 2008).
Through endogenous enzymatic reactions, retinoids are A further randomised, double-blind study comparing twice-
converted to all-trans retinoic acid, which is the functional form daily application of 4% niacinamide with 1% clindamycin
of vitamin A in the skin. Retinols, retinaldehyde and retinyl gel in patients with moderate inflammatory acne found no
esters (e.g. acetate, propionate and palmitate) are available in significant differences between the two groups with regard to
cosmeceutical formulations, whereas retinoic acid (tretinoin) the changes in the mean number of facial papules/pustules at
and its derivatives (adapalene, tazarotene) are prescription-only weeks 4 and 8 (Khodaeiani et al, 2013). However, they did note
pharmaceuticals (Bissett, 2009). that the niacinamide and clindamycin gels were significantly
In 1995, Kang et al performed a controlled study of these more efficacious in oily and non-oily skin types, respectively.
different forms of vitamin A by comparing the clinical, histological This can be explained by the known potent anti-inflammatory
and molecular responses of normal human skin to the application action of niacinamide (Grange et al, 2009; Pietrzak et al, 2009),
of either retinol or retinoic acid (Kang et al, 1995). They found which would be expected to act better in an oily and hence more
that retinol has biologically similar effects to retinoic acid, with inflamed skin (Zouboulis, 2004).
less erythema and irritation (Kang et al, 1995). Retinaldehyde has Acne is associated with impaired skin barrier function, as
also been found to be better tolerated than retinoic acid, and has demonstrated by increased transepidermal water loss (TEWL)
a similar irritation profile to retinol (Fluhr et al, 1999). (Yamamoto et al, 1995). Niacinamide has been shown to reduce
A prospective, double-blind, randomised, multicentre trial by TEWL, giving it the potential to improve barrier function and
Lee et al (2011) compared a cosmeceutical 0.03% retinol cream therefore decrease sensitivity in acneic skin (Tanno et al, 2000;
with a 0.1% adapalene gel in 97 patients with mild-to-moderate Bissett, 2002; Mohammed et al, 2013).
acne. They concluded that there was no statistical difference in Side effects associated with the topical application of
efficacy, with both preparations leading to equal improvement; niacinamide (mild burning, erythema and pruritis) are mild
however, the retinol cream caused less skin irritation (Lee et al, and rare, and improve with continued use (Draelos et al, 2006;
2011). Retinaldehyde (but not retinol or retinoic acid) has been Navarrete-Solís et al, 2011).
shown to have significant in vitro antibacterial activity on Gram-
Alpha hydroxy acids
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positive bacteria, including P. acnes, believed to be an effect of its

aldehyde group (Pechère et al, 2002).
Niacinamide
The active amine form of niacin (vitamin B3) goes by a number of
names, including niacinamide and nicotinamide. Niacinamide,
Alpha hydroxy acids (AHAs) are a group of organic carboxylic
acids that have a hydroxyl group substituted at the alpha carbon
(Table 2). The most commonly used AHAs in clinical practice
are glycolic and lactic acids (Green et al, 2009). AHAs are water-
soluble, but can be made more lipophilic by the addition of

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 Table 2: Alpha hydroxy acids and their sources
Alpha hydroxy acid Source
Glycolic acid Sugar cane
Lactic acid Milk products
Malic acid Apples
Tartaric acid Grapes
Citric acid Citrus fruits
Green et al (2009)
a phenyl group, e.g. phenyl-glycolic (mandolic) acid, thereby
enhancing the ability to target oily and acne-prone skin.
AHAs thin the stratum corneum by reducing cell cohesiveness,
enhancing breakdown and causing desquamation (Araviiskaia
and Dréno, 2016). At low concentrations of 5–10%, AHAs
act on the superficial layers of the skin to cause subcorneal
epidermolysis, opening up comedones and deroofing pustules
(Tung et al, 2000). A double-blind, randomised, placebo
controlled trial using once-daily application of 10% glycolic acid
as monotherapy for mild acne showed signifiant improvement
after 90 days (Abels et al, 2011).
AHAs can be combined with both therapeutically active
ingredients and cosmetic procedures to increase therapeutic
effects, and improve tolerability and outcomes (Green et al,
2009). Several studies to date have also shown the efficacy of
combining glycolic acid and retinaldehyde, both in the treatment
of acne and the management of associated post-inflammatory
hyperpigmentation (Poli et al, 2005; Green et al, 2009).
Salicylic acid
This beta hydroxy acid (BHA), and its derivative lipohydroxy
acid, have comedolytic properties and have both been shown to
be effective in reducing the number of acne lesions by regulating
turnover of the stratum corneum (Araviiskaia and Dréno,
2016). Both AHAs and BHAs have the potential to cause a pH-
dependent irritation of the skin, although this can be avoided
with careful choice of formulation. Salicylic acid formulated at
a pH of 6.50 has been found to induce relatively no stinging
compared with a formulation at pH 3.12 (Merinville et al, 2009).
Fatty acids
Linoleic acid (omega-6), alpha-linolenic acid (omega-3) and
medium-chain fatty acids, such as lauric acid, have a number of
diverse roles that are relevant to acne management, including:
maintenance of the stratum corneum permeability barrier,
inhibition of proinflammatory cytokines and promotion of
wound healing (McCusker and Grant-Kels, 2010).
Two double-blind, placebo-controlled randomised studies
looking at topical linoleic acid showed a 25% reduction in
size of comedones over a 1-month treatment period (Letawe
et al, 1998), and that when used in combination with 4%
niacinamide, it was found to be slightly superior, both in terms
of global clinical improvement and patient compliance, to a 1%
10
Table 3: Natural and botanical agents with
potential use in acne management
Aloe vera
Chamomile
Curcumin
Feverfew
Green tea
Jojoba
Liquorice
Pine bark extract
Seaweed
Soy
Vitamin C
Vitamin E
Witch hazel
Araviiskaia and Dréno (2016); Colantonio and Rivers (2017)
topical clindamycin gel (Morganti et al, 2011). Lauric acid has
been shown to have an antimicrobial effect on P. acnes in both
in vitro and in vivo studies (Araviiskaia and Dréno, 2016).
Other agents
Zinc salts (sulphate and gluconate), when used both topically
and orally in the management of acne, have been shown to have
antibacterial and anti-inflammatory effects, and may decrease
sebum production (Dreno et al, 1992; Brandt, 2013). Tea tree
oil has been shown to significantly improve mild-to-moderate
acne (Malhi et al, 2017), and oat plantlet extract appears to
reduce inflammation and inhibit bacterial adhesion of P. acnes
(Fabbrocini and Saint Aroman, 2014). A number of other natural
ingredients have been shown to have anti-inflammatory,
antioxidant and moisturising properties (Table 3). These may
prove to be useful cosmeceutical acne treatments, although more
research and clinical studies are needed in this respect.
Cleansers and moisturisers
Patients with acne have been found to have an innate reduction
in integrity of the stratum corneum, with increased TEWL, that
correlates with acne severity (Yamamoto et al, 1995). Furthermore,
some topical and oral medications that are used to treat acne can
induce changes within the epidermis that alter barrier functions,
especially the permeability of the stratum corneum (Del Rosso,
2013). The increase in TEWL and decrease in hydration lead to
further skin inflammation, irritation, peeling and symptoms of
skin sensitivity, which make it more difficult to continue with
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further application of topical therapy. Oral isotretinoin also
impairs the integrity of the stratum corneum by causing unsticking
of corneocytes, markedly suppressing sebum production and
altering the cutaneous microflora (Del Rosso et al, 2016).
The integrity of the epidermal barrier function can be both
protected and improved with the use of appropriate cleansers
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 Table 4: Recommended properties of skin
cleansers for use in acne
Foaming—capable of producing enough lather to remove
sebum and other unwanted material, such as dirt, make-up and
desquamated corneocytes, from the skin surface
Easy to apply and rinse off without leaving a residue
Cosmetically pleasing
Minimal potential for inducing skin irritation
Slightly acidic or neutral pH
Alcohol-free
Non-abrasive
Del Rosso (2013); Goh et al (2015)
Table 5: A typical cosmeceutical skincare regimen
used in the author’s clinic for mild-to-moderate
inflammatory acne
Morning Evening
Gentle foaming cleanser Gentle foaming cleanser
Alpha/beta hydroxy acid serum Retinol serum (2250 IU/g)
(lactic/malic/salicylic acid)
Niacinamide 9–15% serum Niacinamide 9–15% serum
Non-comedogenic Non-comedogenic
zinc-based sunscreen moisturiser (if required)
Del Rosso (2013); Goh et al (2015)
and moisturisers, and the importance of integrating these into a
specific skin regimen for acne patients cannot be underestimated
(Del Rosso, 2013). Patient adherence to prescribed acne treatment
is improved if the skin is not irritated, and this adherence can be
increased by the use of appropriate skincare products (Dréno et
al, 2010). Desirable qualities of a cleanser for use in acneic skin
can be seen in Table 4. Table 5 details a typical skincare regimen.
Facial washing with cleansers has been found to reduce both
inflammatory and non-inflammatory lesions when done twice-
daily (Choi et al, 2010). Scrubs or other mechanical treatments can
help facilitate exfoliation of the skin in many patients; however,
these should not be suggested in patients who are known to have
sensitive skin (Goh et al, 2016). Products containing allergens,
such as fragrances and preservatives, should be avoided in
patients with sensitive skin and those with a history of allergic
contact dermatitis (Decker and Graber, 2012).
Moisturisers made specifically for acneic skin have been found
to decrease the dryness and stinging sensation associated with
barrier disruption, therefore improving treatment compliance
(Goh et al, 2016). Ideally, in the context of acne, moisturisers
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should be non-comedogenic, non-acnegenic, hypoallergenic and
non-irritating. Therefore, gels or light creams can be preferable
to heavier creams or ointments. Moisturising agents are often
found incorporated into cleansers or photoprotecting agents and
can be used once or twice a day depending on need (Del Rosso
et al, 2015). Applying moisturiser first, before other agents, can
Supplement 1 2018 ► Journal of AESTHETIC NURSING
reduce the drying and stinging effects of topical pharmaceutical
acne treatments (Goh et al, 2016).
Conclusion
The use of adjuvant skincare has become essential in the
management of acne, and recent advances in cosmeceutical
research have shown a push towards robust clinical trials in
this arena. Although further research is needed, evidence now
exists for the positive impact of a number of cosmeceutical, non-
prescription products on various pathogenic pathways of acne.
Acne is a chronic relapsing condition and cosmeceutical
products, particularly those that target one or more specific
pathogenic pathways, have a role in both the prevention of
new lesions and the maintenance of remission. Cosmeceutical
products tend to be well tolerated and can be used as a single
strategy (Table 5) or synergistically with pharmaceutical agents
(Araviiskaia and Dréno, 2016).
As topical agents have little systemic absorption, using
cosmeceutical preparations as maintenance or treatment options
may be safer than pharmaceutical agents during pregnancy and
lactation (Murase et al, 2014; Patel et al, 2016).
Aesthetic practitioners are commonly asked for skincare
recommendations for patients with acneic skin. Appropriate
use of cosmeceutical agents may augment pharmaceutical acne
treatment, minimise side effects and improve patient compliance.
An understanding of the actions of these agents, the evidence for
their use and any adverse effects should enable practitioners to
effectively and appropriately consult patients on the benefits and
risks of these products.
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