Day to day care for acne – Dr. A. Cohen-Letessier

Progress in the understanding of the physiopathological mechanisms of acne have led to improvement in cosmetic products which target these mechanisms. These new, anti-acne cosmetics are helping in the treatment of this problem, and are used in combination with medical treatments.

Acne is a chronic inflammatory disease of the pilosebaceous follicle and is largely triggered by hormones. Acne is characterized by hyperkeratinisation of the follicular ostia and a spread of Cutibacterium acnes (C. acnes), which is associated with the production of sebum (by the sebocytes) and an alteration of the composition of lipid products (less linoleic acid).
C. acnes is an anaerobic bacterium whose role in induction and maintenance during the inflammatory phase of acne has been recognised for many years. This commensal bacterium on the surface of the skin spreads rapidly in acne lesions and can thus become pathogenic, it represents the majority, more than 80%, of the cutaneous microbiome in acne-affected areas. C. acnes is involved in innate immunity (activation of Toll Like Receptors and Protease Activated Receptors) and stimulates the production of pro-inflammatory cytokines (IL-1β, IL-8, IL-12 and TNFα) which are at the heart of papulopustular lesions in acne. C. acnes is activated by certain receptors (Corticotropin Releasing Hormone Receptor and Insulin Growth Factor Receptor) which leads to an increase in the secretion of sebum by the sebocytes and a spread of keratinocytes (retentional lesions).
One recent discovery is that of the biofilm of C. acnes. The biofilm is a community of bacteria which are capable of secreting a sort of protective glue (glycocalyx). By protecting them the biofilm boosts the spread of these bacteria and also protects them from the action of topicals, this increases their virulence.

Active ingredients used in cosmetics

Many active ingredients are integrated into cosmetics, acting on the various components of acne with targeted properties.
Procerad is a ceramide with anti-inflammatory properties which also acts on acne hyperpigmentation and erythematous scarring, it is used in combination with linoleic acid (which is a normal component in hydrolipidic cutaneous film) which acne-covered skin lacks, and also niacinamide (vitamin PP), a recognized anti-inflammatory.
Phytosphingosine can inhibit the production of IL-1α inflammatory chemokine. Associated with niacinamide, it provides antiinflammatory and antibacterial actions.
Lipo-hydroxy-acid, salicylic acid and glycolic acid are active ingredients that target hyperkeratinisation.
Some active ingredients target biofilm: by dispersing it, this allows antibacterial agents and antibiotics to reach C. acnes colonies within the pilosebaceous follicle. They also possess anti-inflammatory properties and some of them have anti-bacterial properties. Such agents include: ceramides, myrtacine, niacinamide and diolenyl.
Myrtacine, a natural extract from mediterranean myrtle, has antibacterial properties and it targets the biofilm, penetrating into the follicle to act alongside the local antibiotic treatment.
Diolenyl (octane 1-diol), used in combination with linoleic acid, Xpressin monolaurin (which regulates the hyper-production of sebum) is an anti-bacterial agent which is effective against C. acnes. This treatment attempts to improve the texture of the skin.

Soothing, cleansing and protecting the skin

Active cosmetics for acne include both soothing agents and hydrating agents. The composition of these products takes into account the drying effects of the medical treatments prescribed for acne. It is very important to combine cosmetics with the targeted treatments which cause irritation and a drying of the skin, without cosmetics the patients are likely to stop their treatment. Furthermore, the targeted anti-acne cosmetics lighten the medical treatment, especially antibiotics.
Hygiene products must be adapted - whether it be cleansing lotions or foaming gels which respect the physiology of the skin and do not strip it away (this would lead to an activation of sebaceous secretion).
Photoprotection plays a key role in acne. Exposure to sunlight leads to a thickening of the skin whilst the objective of the acne treatment is to thin the skin in order to unblock the pilosebaceous follicles. The sun is a false friend in the treatment of acne and almost always causes the spots to come back. High factor sun cream (minimum factor 30) is therefore recommended.
Thanks to the progress made in anti-acne cosmetics and in the highly effective targeted medicinal topicals (tretinoin, adapalene, etc.) the role of microsurgery has been reduced in acne. Microsurgery can still be carried out in order to speed up the evacuation of the micro-cysts prior to the medical treatment. We must not forget other active dermatological products such as Alpha hydroxy acids (AHA) and Beta hydroxy acids (BHA) which have been very useful and very widely used, as well as covering products (make-up and camouflage) which are particularly important whilst patients are waiting for the treatment to have its full effect (this takes between 2 and 3 months).

This article has been written by Dr. A. Cohen-Letessier, dermatologist (Paris, France)