Received: 4 July 2022 | Revised: 3 November 2022 | Accepted: 7 November 2022

DOI: 10.1111/jocd.15519

REVIEW ARTICLE

Expert consensus on holistic skin care routine: Focus on acne,

rosacea, atopic dermatitis, and sensitive skin syndrome

Chee-­Leok Goh MD, MBBS, MRCP(UK), MMed(Int Med), FACD(Hon)1 | Yan Wu MD, PhD2 |
Belinda Welsh MBBS, MMed, FACD3 | Ma Flordeliz Abad-­Casintahan MD, FPDS4 |
Chung-­Jen Tseng MD5 | Jaishree Sharad MBBS, DDV, IFAAD6 | SungKyu Jung MD, MS7 |
Jinda Rojanamatin MD8 | Irma Bernadette S. Sitohang MD, PhD9 |
Hau Ngai Kingsley Chan MBBS (HK), MRCP (UK), Dip Derm (Glas), FHKCP, FHKAM (Medicine),
FRCP (Glasg), FRCP (Edin)10

1
National Skin Centre, Singapore,
Singapore Abstract
Background: Treatment, cleansing, moisturizing, and photoprotection are four major
2
Department of Dermatology, Peking
University First Hospital, Beijing, China
3
components of holistic skin care for dermatological conditions. While treatment (T)
Director Complete Skin Specialists,
Melbourne, Victoria, Australia is recognized as a key component in the management of dermatological conditions,
4
National Specialty Center for there is a lack of practical guidance on the adjunctive role of cleansing, moisturizing,
Dermatology, Jose R. Reyes Memorial
and photoprotection (“CMP”). Limited patient knowledge, confusion over product
Medical Center, Manila, Philippines
5
Taiwanese Society for Dermatological selection, and lack of guidance on how to choose and use CMP skin care products
and Aesthetic Surgery, Taiwan, China (in conjunction with pharmacological therapy) are the main barriers to establishing a
6
Skinfinitii Aesthetic Skin and Laser Clinic,
holistic skin care routine for dermatological conditions.
Mumbai, India
7
Doctors Dermatology Clinic, Jamsil and
Aims: This study aimed to review current clinical evidence, identify gaps, and provide
Songpa Clinic, Seoul, South Korea practical guidance on conceptualization and implementation of CMP routine in the
8
Rajavithi Hospital, Bangkok, Thailand management of sensitive skin due to underlying acne, atopic dermatitis, or rosacea,
9
Department of Dermatology and
including conditions with idiopathic causes referred to as idiopathic sensitive skin
Venereology, Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia syndrome.
10
Honorary Consultant Dermatologist, Methods: An expert panel comprising of 10 dermatologists from Australia, China,
The Hospital Authority, Hong Kong, China
Hong Kong, Taiwan, India, Indonesia, Philippines, Singapore, South Korea, and
Correspondence Thailand convened to develop consensus statements on holistic skin care in acne,
Chee-­Leok Goh, National Skin Centre,
1 Mandalay Road, Singapore 308207, rosacea, atopic dermatitis, and idiopathic sensitive skin syndrome using the Delphi
Singapore. approach.
Email: drgohcl@gmail.com
Results: Consensus was defined as ≥80% of panel rating statement as ≥8 or median
Funding information rating of ≥8. The final statements were collated to develop consensus recommenda-
Galderma
tions on holistic skin care.
[Correction added on 9th March 2023, Conclusion: A dermatologist-­guided holistic skin care routine is essential to improve
after first online publication: Tenth
affiliation has been updated in this
patient confidence and reduce confusion over product selection. The consensus rec-
version.] ommendations presented here highlight the importance of cleansing, moisturization,

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,
provided the original work is properly cited.
© 2022 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.

J Cosmet Dermatol. 2023;22:45–54.  wileyonlinelibrary.com/journal/jocd | 45

 |
46
and photoprotection in holistic skin care and how it can be utilized as a communi-
cation tool for physicians and patients to achieve overall better patient compliance,
satisfaction, and treatment outcomes.
KEYWORDS
holistic care, moisturizers, photoprotection, sensitive skin, skin cleansers
1 | I NTRO D U C TI O N
Treatment, cleansing, moisturizing, and photoprotection constitute
the four major components of skin care routine for dermatological
1
conditions. While therapeutic guidelines for the management of
atopic dermatitis, acne, and rosacea exist, there is a lack of practical
recommendations on the importance of cleansing, moisturizing, and
photoprotection (“CMP”). Despite an increasing demand for these
skincare products, there are several unmet needs and challenges in
the implementation of CMP in clinical practice.
About 40% of consumers are purchasing skincare products upon
the recommendations of acquaintance rather than base on derma-
2
tologists' guidance. Limited patient knowledge of skin condition,
lack of educational materials, and inadequate time for patient ed-
ucation during dermatological consultations, are the main obsta-
cles to establishing a CMP routine in holistic skin care routine.3,4
Additionally, the wide range of over-­the-­counter (OTC) skincare
products with different compositions is overwhelming for patients
and hinders appropriate product selection.3 This is reflected in the
high incidence of side effects (23.8%) associated with the inappro-
2
priate use of skincare and cosmetic products.
Most patients consider dermatologists as the highly trusted
source of information on skin care product recommendations and
expect dermatologist guidance on proper use of products. 2 Patients
are four times more likely to follow dermatologist's direction when
product information is provided. Patient education is a crucial factor
in promoting patient compliance and communication with dermatol-
ogist is an important element driving patient satisfaction, implying
5
the need for dermatologist guided skin care routine.
Although treatment, cleansing, moisturizing, and photoprotec-
tion are the four major components of holistic skin care plan for the
management of dermatological conditions, therapeutic treatment
is the key component. Nevertheless, inclusion of recommendations
on therapeutic management of acne, rosacea, and atopic dermatitis
is beyond the scope of this publication, which have been published
elsewhere. It is beyond doubt that holistic skin care should focus on
therapeutic treatment first while considering individual skin differ-
ences and understanding product details to include cleansing, mois-
turization and photoprotection in accordance with different stages
of the disease course. However, there is a lack of practical guidance
on the role of cleansing, moisturizing, and photoprotection in holistic
skin care. To fulfill this unmet need, this paper aims to focus on the
adjunctive role of CMP in alleviating signs and symptoms of the skin
conditions and improving quality of life.
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GOH et al.
2 | M E TH O D O LO G Y
This study aimed to review current clinical evidence, identify
gaps, and provide practical guidance on the implementation of
holistic skin care routine in the management of sensitive skin
conditions as observed in acne, atopic dermatitis, rosacea, and
idiopathic sensitive skin syndrome, since these are among the
most encountered skin conditions in clinical practice in the Asia
Pacific region.
Sensitive skin syndrome is a condition characterized by stinging,
burning, pain, pruritus, and tingling sensations in response to stim-
uli that normally should not elicit such sensations. These unpleasant
sensations cannot be explained by lesions attributable to any skin
disease.6 Sensitive skin syndrome may be seen in conditions such as
acne, atopic dermatitis, or rosacea or it may be idiopathic without
any underlying skin conditions.7 Due to its complexity, the diagnosis
and treatment of sensitive skin are beyond the extent of this paper;
instead, we focus only on CMP components of holistic skin care for
sensitive skin syndrome.
An expert panel comprising of 10 dermatologists from
Australia, China, Hong Kong, Taiwan, India, Indonesia, Philippines,
Singapore, South Korea, and Thailand was selected based on their
dermatological experience and expertise. The panel conducted a
PubMed literature search and extracted articles in English pub-
lished between January 2010 and October 2020. Search terms
used were “atopic dermatitis,” “acne vulgaris,” “rosacea,” “sensi-
tive skin”, “skin care,” “patient education,” “practice guidelines,”
“skin cleansing,” “emollients,” “moisturizers,” “photoprotection,”
“sunscreens,” “sun protection factor,” and “detergents.” The panel
drafted consensus statements on holistic skin care in acne, rosa-
cea, atopic dermatitis, and sensitive skin syndrome. Publications
were prioritized with guidelines from international society and ex-
pert opinions considered to provide the highest level of evidence,
followed by randomized controlled trials, reviews, and clinical
case studies.
An iterative Delphi approach was employed to develop consen-
sus as per the Delphi inclusion criteria.8 (Figure 1 and Table 1).
3 | R E S U LT S
Based on the literature search results, the panel drafted 46 con-
sensus statements which were included in the iterative Delphi
approach survey. Of the 46 draft statements, 18 statements
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GOH et al. 47

F I G U R E 1 Delphi Survey Process of consensus generation and refinement

TA B L E 1 Iterative Delphi technique inclusion criteria

Statement outcome Threshold applied

“Definitely include” (Consensus) ≥80% of panel rate statement as ≥8 OR Median rating of ≥8

“Maybe include” (Critical consensus)
“Definitely exclude”
To review
70% of panel rate statement as ≥8 OR Median rating of ≥6
<70% of panel rate statement as ≥8 AND 100% panel understand statement OR
Median ≤5 AND 100% panel understand statement
(i.e., low scores are not due to lack of understanding of item)
Major revisions suggested OR
<70% of panel rate statement as ≥8 AND < 100% panel understand statement (i.e., low scores are not
due to lack of understanding of item)

obtained a threshold of “definitely include” (median score of ≥8, 4 | DISCUSSION

OR ≥ 80% of panel rate as ≥8), while 24 statements needed dis-
cussion and refinement as they fell into threshold of “to review”
despite obtaining a threshold of “definitely include” (for e.g., me-
dian score ≥7, but <70% of panel rate as ≥8 and <100% of panel
understand statement). Four statements were in the category of
“definitely exclude” (i.e., median score ≤5 and 100% of panel un-
derstand statement, low scores are not due to lack of understand-
ing of item) Table 1. The statements selected for refinement were
discussed and finalized through live voting. Five statements with
similar meaning or content were deleted, and 4 additional state-
ments on photoprotection were added to generate a final of 41
statements, which were collated to develop consensus recommen-
dations on holistic skin care in sensitive skin syndrome associated
with acne, atopic dermatitis, rosacea, and idiopathic sensitive skin
syndrome. The process of refinement of statements is shown in
Figure 2 The statements are presented in Tables 2, 3, 5 and 7.
4.1 | Challenges in implementation of holistic skin
care
The expert panel emphasizes the importance of CMP components
of holistic skin care and highlights the unmet needs, particularly,
the lack of practical guidance, for both patients and physicians on
the implementation of CMP routine in clinical practice, as outlined
in Table 2. Limited patient knowledge about the skin conditions,
time constraints of busy dermatological practices limiting patient
education opportunities, and overwhelming choice of OTC prod-
ucts increase the risk of inappropriate use of skin care products,
and hamper treatment outcomes. 3,4 For example, side effects such
as dryness, irritation, and photosensitivity are the main reasons
for poor patient compliance with acne therapy. 3 Paucity of patient
guidance on the appropriate use of CMP routine to mitigate these
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48 GOH et al.

F I G U R E 2 Generation and refinement process of recommendation statements

TA B L E 2 Consensus on importance of holistic skin care and challenges

Vote
(%)

Importance of holistic skin care

Four major components of holistic skincare routine are cleansing, moisturizing, medicating, and sun protection. 100
An effective skincare routine improves patients' quality of life, self-­esteem, and self-­image. 80
Holistic skincare routine improves symptoms and reduces side effects from topical therapy of certain skin conditions, thereby 80
improving treatment adherence. For example, it can have steroid-­sparing effects in atopic dermatitis and reduce the need for
antibiotics for acne patients.
Appropriate skincare (e.g., in atopic dermatitis) reduces incidence of flares, increases time between flares and reduces the number of 90
lost days at work.
Challenges and unmet needs in implementation of holistic skin care
There is a lack of practical guidance on holistic skin care focusing on cleansing, moisturizing, and photoprotection, for physicians and 90
patients.
Side effects of topical therapy, lack of patient awareness (e.g., where, how to and how much medication to apply) and inappropriate 90
use of cleansers and moisturizers contributing to poor treatment adherence need to be addressed.
Some topical therapies (e.g., in acne) may adversely affect skin barrier function, increase sensitivity, and predispose skin to sun 100
damage, leading to reduced compliance and poor treatment outcomes.
Misconceptions among patients (e.g., acne is caused by dirt) lead to misuse of skin care products, which in turn exacerbates the skin 100
condition.
Limited patient knowledge, inadequate self-­management, and lack of effective physician-­patient communication are significant barriers 100
to effective treatment.
Patient education on holistic skincare routine is essential to improve disease awareness, manage expectations, and enhance treatment 90
adherence.
Dermatologist guided skincare routine will improve patient confidence, compliance, and reduce confusion over product selection. 90
Asian skin is different from Caucasian skin and reacts differently to topical agents. Dermatologists should consider these differences 100
while prescribing topical therapies

Vote count—­based on 10 experts.

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GOH et al. 49

TA B L E 3 Consensus recommendations
Vote
on cleansing in holistic skin care
(%)

Cleansers should effectively and gently remove the dirt and excessive lipids, should not 100
irritate, or dry the skin and should help to absorb topical medications.
Inadequate use of cleansers can compromise clinical outcome, patient satisfaction, and 100
treatment adherence.
Proper use of cleansers supplements therapeutic management to improve and reduce 100
acne lesions, reduce side effects of acne therapy, and thereby improve compliance.
Once to twice daily short lukewarm water baths, followed by immediate application of 100
moisturizes are recommended for AD patients.
Cleansers with neutral to acidic pH compatible with normal skin are recommended in 100
atopic dermatitis and other conditions associated with sensitive skin syndrome.
Synthetic detergents, which have less than 10% soap are less irritating and drying to 100
the skin and are suitable for patients with sensitive skin.
Appropriate use of cleansers can improve barrier dysfunction, restore skin hydration, 100
and microbiome, normalize skin pH, and improve symptoms of rosacea.
Cleansers should be non-­comedogenic, non-­acnegenic, non-­allergenic, non-­irritating, 90
and compatible with patients' skin type.

TA B L E 4 Consensus recommendations on desired characteristics of cleansers

Desired characteristics in cleansers for acne, atopic dermatitis, rosacea, and other conditions associated with sensitive skin syndrome

• Non-­irritating
• Non-­allergenic
• Non-­comedogenic
• Fragrance free
• Alcohol free
• Mildly acidic pH
• Maintain and improve skin barrier function

Other conditions associated with

Acne Atopic dermatitis Rosacea sensitive skin syndrome

• Remove excess sebum • Soap free • Soap-­free • Soap free

• Non-­acnegenic • Effectively and gently cleanse dry, • Should not contain astringents, • Minimal ingredients (<15)
• Contains anti-­acne itchy skin toners, camphor, menthol, or
ingredients • Provide immediate and long-­ acetone
lasting hydration

side effects is a significant hurdle in improving patient compliance.
Based on the clinical experience, the panel highlights the lack of
patient understanding on how to choose and use CMP in conjunc-
tion with pharmacological therapy, how to avoid triggers, and how
to use sun protection as major unmet needs in implementation of
holistic care.
These challenges emphasize the need for a dermatologist-­guided
skin care routine to improve patient confidence and reduce confu-
sion over product selection.3 The panel advocates a patient-­centric
approach based on patient factors and preferences focusing on
education and practical recommendations on appropriate use of
cleansers, moisturizers, and sunscreens. Readily available patient
educational material, practical instructions, and staff training are
recommended for improving patient and physician awareness on
holistic skin care routines.4,9
With the plethora of products available on the market, it
is not easy for physicians to verify the truthfulness of product
claims, such as hypoallergenic, non-­irritating, non-­a llergenic, non-­
comedogenic, and non-­a cnegenic. Physicians should be aware
that such common claims are marketing tools with minimal reg-
ulatory validation.10 Physicians should look at proof of efficacy
studies to validate claims such as skin hydration, transepidermal
water loss, hypoallergenic, or UV protection. Physicians should
consider the key ingredients and supporting scientific evidence
before prescribing skin care products. For example, benzoyl per-
oxide in strengths of up to 10% and salicylic acid in strengths of
up to 2% are FDA approved ingredients in OTC acne products.11
With reference to cosmetics, physicians should be cognizant with
the term “alcohol-­f ree” products, because alcohol-­f ree refers to
the solvent ethyl alcohol, which can cause skin dryness. However,
alcohol-­f ree products can also contain “fatty alcohols” such as
cetyl, stearyl, cetearyl, or lanolin alcohol, which can be confusing
in an alcohol-­f ree product claim. On the contrary, fatty alcohols
are skin friendly as they help to retain moisture. In context with
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50 GOH et al.

TA B L E 5 Consensus recommendations on moisturization in holistic skin care

Vote
(%)

Moisturizers play a crucial role in skincare routine by improving skin hydration and barrier function. 90
Moisturizers reduce skin dryness and irritation associated with topical acne therapy, thereby improve compliance and treatment 100
outcomes.
Moisturizers are the mainstay of atopic dermatitis treatment. Moisturization improves skin barrier function, has steroid-­sparing effect, 100
reduces incidence of flares, and increases the time between flares.
Moisturizers are recommended for all levels of atopic dermatitis severity—­for primary prevention, maintenance, prevention of relapse, 100
and during acute flares.
Moisturizers for rosacea should contain humectant and occlusive agents to replenish epidermal lipids, retain moisture, and repair barrier 100
function.
Therapeutic moisturizers are particularly formulated to address specific symptoms related to skin condition. (e.g., itch, inflammation). 90
Moisturizers should be applied immediately after bathing, and frequently and liberally with at least 4–­5 applications per day. 100
Fragrances, preservatives (e.g., formaldehyde) and tocopherol are the most common allergens in moisturizers and should be avoided in 100
patients with sensitive skin.
Anti-­aging products with cell-­stimulating ingredients and products containing astringents, toners, camphor, menthol, alcohol, or acetone 100
should be avoided in patients with rosacea.
An ideal/recommended moisturizer for AD patients should protect skin barrier function and may contain anti-­inflammatory and 100
antioxidant properties.
Patient-­centric approach focusing on patient factors and preference while choosing an appropriate moisturizer will ensure patient 100
compliance.
Patients should be educated on the need for regular moisturization and receive practical tips on the appropriate use of moisturizers. 100

therapeutic moisturizers, as per the US FDA over-­t he-­counter
monographs, only products containing hydrocortisone or colloi-
dal oatmeal can claim to provide eczema relief.12 It is noteworthy
that the regulation of ingredients and claims in cosmetics vary
across countries. For instance, benzoyl peroxide is not allowed to
be listed as a cosmetic ingredient in certain areas, while products
containing colloidal oatmeal cannot claim to provide eczema relief
in some others, thus requiring individualized consideration. The
consensus panel, therefore, emphasizes the role of dermatologist
guided CMP routine to reduce patient confusion over unsubstan-
tiated product claims.
4.2 | Consensus recommendations on cleansing
Cleansing (C) forms a vital component of holistic skin care. Studies
have documented beneficial effects of cleansing in acne with re-
moval of sebum leading to reduction in both inflammatory and non-­
13
inflammatory acne lesions. The panel recommends that cleansers
for acne should be non-­irritating, non-­allergenic, non-­comedogenic,
non-­acnegenic and alcohol-­free while also removing excess sebum.
Cleansing frequency recommendation varies across countries
mainly depending on climatic conditions. In hot, tropical climates
cleansing is recommended up to three times a day, while in dry, win-
ter climates twice daily cleansing is sufficient. The panel advises
against excessive cleansing as it can lead to skin dryness and ir-
ritation, which can adversely affect topical therapy compliance and
clinical outcomes.
Highlighting the benefits of cleansing in atopic dermatitis (AD),
a randomized control trial, showed that body wash formulae with
lipids and zinc pyrithione significantly reduced the colonization of
staphylococcus aureus, improved microbial diversity, reduced corti-
costeroid consumption, and showed clinically important improve-
ment from baseline in SCORAD (SCORing Atopic Dermatitis) at the
end of 4 weeks.14 Because cleansers with alkaline pH can strip pro-
teins, lipids, and natural moisturizing factors off the stratum cor-
neum,15 the panel recommends non-­soap cleansers with neutral to
acidic pH, hydrating cleansers that leave a film of moisturizer over
the skin surface and short, lukewarm baths for AD patients.
The benefits of cleanser and moisturizer regimen have also been
demonstrated in the Assessment of Skin Characteristics Study, a
multicenter open-­label study, which showed reduced severity and
duration of stinging, burning, tingling, and itching in rosacea.16
Patients with rosacea have sensitive skin, and since detergents
containing sodium lauryl sulfate can cause skin irritation, soap-­free
cleansers are recommended.17 Synthetic detergents (syndets) are
preferred because they are soap free and their pH is compatible with
natural skin.15 To avoid any potential irritants, cleansers for rosacea
and other sensitive skin disorders should be alcohol free and should
contain minimal mild surfactants. Products containing astringents,
tonics, camphor, or menthol should be avoided.17 Fragrance free
cleansers are preferred as they reduce the risk of sensitization and
contact allergy.
Properties such as alcohol-­free, soap-­free, and sodium lau-
ryl sulfate-­free should not be considered by all-­or-­none manner.
Different ingredient concentration and formulation could lead to
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GOH et al. 51

different product property. Although alcohol is added to skin care
products to make the product feel light, allow better absorption of
ingredients or as a preservative, alcohol can disrupt the skin bar-
rier and cause skin dryness. Consequently, alcohol-­free cleansers
are preferred in those predisposed to skin dryness. Depending on
their molecular charge, surfactants in cleansers are either anionic,
cationic, amphoteric, or non-­ionic. Anionic surfactant like sodium
lauryl sulfate (SLS) is a common ingredient in cleansers because of
its foaming and lathering characteristics. However, the irritation
potential of each surfactant is different. For example, both SLS and
sodium cocoyl isethionate (SCI) are anionic surfactants, but SLS
causes significant skin irritation. Combining sodium laureth sulfate
(SLES) (anionic surfactant closely related to SLS) with amphoteric
surfactants results in a milder cleanser formula with reduced skin
15
irritation. The consensus recommendations on cleansing and de-
sired characteristics of cleansers are summarized in Tables 3 and 4.
4.3 | Consensus recommendations on
moisturization
Moisturization plays a crucial role in holistic skin care by improv-
ing skin hydration and barrier function, the recommendations for
which are summarized in Table 5. Clinical evidence in AD demon-
strates the efficacy of moisturizers in reducing symptoms (e.g., pru-
ritus, erythema, and fissuring) and requirement of anti-­inflammatory
treatment.18 In a Cochrane pooled analysis of six studies, daily
moisturization significantly reduced the number of flares, increased
the time to flare, and reduced the use of topical corticosteroids as
compared with untreated controls.19 By reducing the number of
flares, moisturizers can improve quality of life, reduce sick days at
work, and thus provide potential cost benefit.12 The panel recom-
mends liberal and frequent application of moisturizer at least 2–­3
times daily and immediately after shower in AD patients. (Table 6)

TA B L E 6 Consensus recommendations on desired characteristics of moisturizers

Desired characteristics in moisturizers for acne, atopic dermatitis, rosacea, and other conditions associated with sensitive skin syndrome

• Restore and strengthen skin barrier

• Improve stratum corneum hydration
• Soothe, moisturize, and protect the skin from irritation
• Improve local tolerance to topical treatment
• Should not affect efficacy of topical treatment
• Hypoallergenic
• Non-­acnegenic
• Fragrance free

Other conditions associated with

Acne Atopic dermatitis Rosacea sensitive skin syndrome

• Alcohol free • Provide sustained hydration after single • Alcohol free • Non-­allergenic
• Non greasy application • Non greasy • Minimal ingredients
• Water based Provide immediate relief from itching, redness, and Water based
irritation

TA B L E 7 Consensus Recommendations on Photoprotection in Holistic Skin Care

Vote
(%)

Photoprotection is necessary for all patients to reduce risk of sunburn, photoaging, and triggering of underlying skin condition. 90
a
Appropriate photoprotection helps to prevent post-­inflammatory hyperpigmentation and reduce photodermatitis resulting from oral
and topical therapy.
Broad-­spectrum (UVA and UVB) sunscreen with sun protection factor (SPF) 30+ and SPF/UVA-­PF ratio <3 is recommended in acne, 100
along with sufficient and proper application.
Broad-­spectrum (UVA and UVB) sunscreens with SPF 30+ and SPF/UVA-­PF ratio <3 is recommended to prevent UV induced flares and 100
long-­term photodamage in rosacea.
Regular and adequate use of broad-­spectrum sunscreens with SPF30+ and with inorganic UV filters (titanium dioxide and zinc oxide) is 90
recommended in atopic dermatitis.
Patient education on avoidance of triggers, importance of photo protection, and need for long-­term management for rosacea is needed. 100
a
Physical sunscreens with minimum ingredients and lower allergenic potential are preferred for sensitive skin conditions due to acne,
rosacea, and atopic dermatitis.
a
Choice of sunscreen should be based on patient need and preference, underlying skin condition, and skin phototype.
a
Patient education on appropriate use of sunscreens along with avoidance of midday sun and use of protective clothing is essential.
a
No polling data. These were modified during the manuscript development stage with approval from all authors.
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52
Moisturizers used in AD should provide sustained hydration after
single application, as well as soothe, moisturize, and protect the skin
from irritation. Moisturizers should restore and strengthen skin bar-
rier and provide immediate relief from itching, redness, and irrita-
tion. Additionally, moisturizers should be easy to apply to the skin,
should not leave a greasy film, and should not stain clothing. The
type of moisturizer recommended should be based on patient pref-
erence to ensure compliance. Moisturizers with known irritants, and
sensitizers should be avoided.
It should be noted that all moisturizers are not equal. Emollients
(e.g., Vaseline) provide lubrication and skin softening, occlusive in-
gredients (e.g., liquid paraffin) provide barrier protection and re-
duce water loss, while humectants (e.g., glycerine) attract and bind
water. Therapeutic moisturizers are particularly formulated with
ingredients that counter specific symptoms such as itch (e.g., col-
loidal oatmeal) and inflammation (e.g., hydrocortisone) or target un-
derlying barrier disruption or ceramide deficiency (e.g., ceramides
and urea). 12
Prescription emollient devices (PED) are topical agents
(anti-­inflammatory, humectants, or emollients) used in atopic der-
matitis to target defects in skin barrier function through physically
mediated effects. PEDs are FDA approved as 510(k) medical devices
based on their ability to demonstrate equivalence to already existing
barrier creams.12
Moisturizers are crucial in improving treatment adherence by
mitigating skin dryness and irritation, which are the common side
effects of acne therapy. 20,21 In mild–­moderate acne, a regimen of
cleanser and an active formulation moisturizer reduced the mean
total lesion count (6.9% vs. 1.4%), pustular lesions (p < 0.05), and
sebum levels (p < 0.01) and reduced colonization of Propionibacterium
22
acne (49.4% vs. 3.2%) compared to vehicle. However, it is essen-
tial to note that acne therapies such as benzoyl peroxide and ret-
inoids can affect epidermal barrier function and may cause skin
23
irritation specifically during initial application. Therefore, water-­
based moisturizers are preferred in acne as indicated in Table 6. The
panel advises that moisturizers for acne should improve stratum
corneum water content, should not affect the efficacy of topical
acne treatment, and should improve tolerance to topical treatment.
Additionally, hypoallergenic, alcohol-­free, and water-­based moistur-
izers are recommended.
In another study a skin care regimen of redness control moistur-
izing cream, night repair cream, and facial wash reduced transepi-
dermal water loss (TEWL) (p < 0.001) and increased skin hydration
(p < 0.001) in patients with rosacea. 24 Similarly, Hawkins et al demon-
strated the benefits of a mild cleanser and moisturizer regimen in pa-
tients with self-­perceived sensitive skin and dermatologist-­assessed
sensitive skin (with rosacea and AD). A significant reduction in
dermatologist-­assessed dryness, erythema, and severity of skin
condition was noted with increased skin smoothness, softness, and
overall appearance. 25
The panel recommends that moisturizers should be hypoal-
lergenic, alcohol-­f ree, water-­b ased, and non-­greasy, to avoid irri-
tation of the sensitive skin. (Table 6) Water-­b ased products have
water as the main ingredient, feel light on the skin and offer a
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GOH et al.
cooling effect due to water evaporation from the skin surface.
Non-­greasy products are beneficial as they do not leave greasy
films after application and are less occlusive. For sensitive skin,
moisturizers with hydrophilic formulations and low lipid content
are preferred because those with high lipid content such as min-
eral oils can lead to heat accumulation and worsen some skin con-
ditions.17 Moisturizers for sensitive skin syndrome should restore
barrier function and reduce water loss. Moisturizers with hydrat-
ing agents that retain water (glycerine, hyaluronic acid, or cera-
mides) are beneficial while the use of products containing irritants
(e.g., benzoic acid, sodium lauryl sulfate) should be minimized in
sensitive skin syndrome.7 The panel highlights the unmet need
for moisturizers with active ingredients to address the underlying
pathogenesis of sensitive skin syndrome.
4.4 | Consensus recommendations on
photoprotection
Photoprotection (P) constitutes the third important component of
holistic skin care. Ultraviolet (UV) radiation is known to affect skin
barrier function, trigger skin inflammation, and aggravate atopic der-
matitis and rosacea. 26 UV radiation can also increase the thickness
of the stratum corneum and cause microbial dysbiosis and thus ag-
gravate acne flares. 26 Furthermore, some topical and systemic acne
therapies can increase the risks of phototoxicity. 26 Physicians should
therefore educate patients on avoidance of midday sun and use of
protective clothing as the first essential steps for photoprotection
along with use of sunscreens.
Because the use of photoprotective moisturizer has demon-
strated reduced skin irritation and improved tolerability of topical
medication in acne patients, 23 the panel recommends use of broad
spectrum (UVA/UVB) SPF ≥30 sunscreen to reduce acne therapy-­
induced photosensitivity and photodermatitis, as summarized in
Table 7. Photoprotection, including protection from visible lights is
particularly essential in Asian patients because Asian skin (mainly
Fitzpatrick skin type IV and V) is more prone to post-­inflammatory
hyperpigmentation.3 Sunscreen should be prescribed as early as
possible, notably in young patients, to develop good skincare habits.
Since Asian skin may react differently to topical agents, dermatolo-
gists should consider differences between Asian and Caucasian skin
when prescribing sunscreens.
In patients with sensitive skin due to underlying acne, atopic
dermatitis or rosacea, and idiopathic sensitive skin syndrome, sun-
screen selection needs careful consideration to avoid potential
irritants and allergens. Patients should be asked about previous
intolerance, irritant, or allergic experience. Inorganic UV filters (ti-
tanium dioxide and zinc oxide), also known as physical filters, have
lower allergenic potential and are therefore preferred in sensitive
skin conditions. Sunscreen should not be applied over inflamed
skin to prevent systemic absorption and photosensitization, an
unmet need for sunscreens that can be applied over inflamed skin
is identified. 26 The panel recommends broad-­spectrum (UVA/

GOH et al.
UVB) sunscreen with SPF 30 for atopic dermatitis and rosacea.
(Table 7).
5 | CO N C LU S I O N
Conditions such as acne, rosacea, and atopic dermatitis have under-
lying differences in pathogenesis and treatment, thus requiring in-
dividualized treatment and personalized skin care. While treatment
is a definitive therapeutic component in the management of these
conditions, adjunctive treatment is just as important in alleviating
symptoms and signs of the disease, reducing the use of therapeutic
agents and their side effects and improving the quality of life. It is
crucial to initiate therapeutic treatment first and consider individual
skin differences and understand product details to include cleans-
ing, moisturization, and photoprotection (CMP) in accordance with
different stages of disease course. The consensus recommendations
presented here provide practical guidance on role of CMP in holistic
care to achieve overall better patient compliance, satisfaction, and
treatment outcomes.
AU T H O R C O N T R I B U T I O N S
The authors confirmed contribution to the paper as follows: All
authors had participated in an online survey, and had attended the
expert meeting conducted online, held on March 4, 2022, the dis-
cussion of which formed the basis of this manuscript. All authors
have made substantial contributions to conception and design, ac-
quisition of data, and analysis and interpretation of data. CL Goh
has been involved in drafting the manuscript or revising it criti-
cally for important intellectual content. All authors had reviewed
the results, read and approved the final version of the manuscript
and agreed to be accountable for all aspects of the work. None of
the authors received any honorarium for the preparation of the
manuscript.
AC K N OW L E D G M E N T
This paper was compiled based on discussions during an online ex-
pert meeting convened on March 4, 2022, attended by all authors
and sponsored by Galderma Singapore. The content reflects the
opinion of the authors. None of the authors received any hono-
rarium for the preparation of the manuscript. The authors wished
to acknowledge Dr Sheila Chua, Head of Medical Affairs, Galderma
Japan, and Asia Pacific region, and Dr Vaijayanti Karandikar and See
Mee Yen of Medica Comms, for assistance with the preparation of
this publication.
C O N FL I C T O F I N T E R E S T
All authors have served as consultants for Galderma as advisory
board members. CL Goh is a consultant to Neoasia (Singapore) and
has served on advisory boards for Cantabria Lab (Spain), Galderma,
and LaRoche Posay. B Welsh received honorarium for consultancy
work for Galderma, Eli Lilly, Sanofi Aventis, AbbVie, Janssen-­Cilag,
and Candela. M F Abad-­C asintahan is a consultant Dermatologist
|
14732165, 2023, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocd.15519 by Schweizerische Akademie Der, Wiley Online Library on [29/01/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
53
and Medical Director for Galderma, Philippines. The other authors
have nothing to disclose.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
E T H I C A L A P P R OVA L
Authors declare human ethics approval was not needed for this
study.
ORCID
Jaishree Sharad https://orcid.org/0000-0003-2756-9486
Irma Bernadette S. Sitohang https://orcid.
org/0000-0002-2753-6716
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How to cite this article: Goh C-L, Wu Y, Welsh B, et al.
Expert consensus on holistic skin care routine: Focus on
acne, rosacea, atopic dermatitis, and sensitive skin syndrome.
J Cosmet Dermatol. 2023;22:45-54. doi:10.1111/jocd.15519