Ceramide-Containing Skin Care May Improve Prescription Acne Treatment Adherence

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In a recent review published in the Journal of Cosmetic Dermatology¹, a panel of 9 dermatologists met and concluded that ceramide-containing skin care may help enhance acne treatment and adherence by combatting skin barrier irritation from topical medications such as retinoids, antibiotics, and benzoyl peroxide (BPO).

To understand acne’s socioeconomic and psychological effects on adolescents and young adults, a panel including Lawrence Schachner, MD, FAAD, FAAP; Andrew Alexis, MD, FAAD; Anneke Andriessen, PhD; Diane Berson, MD, FAAD; Michael Gold, MD, FAAD; David Goldberg, MD, JD, FAAD; Shasa Hu, MD, FAAD; Jonette Keri, MD, FAAD; Leon Kircik, MD, FAAD, and Heather Woolery-Lloyd, MD, FAAD, met in early 2023 to first review current literature about skin barrier dysfunction in acne, prescription and over the counter acne treatments, and skin care including cleansers and moisturizers for acne patients. The panelists then drafted 5 final statements from 13 draft statements based on the reviewed literature and their clinical expertise.

Statement #1: The pathophysiology of acne (including comedogenesis, inflammation, and follicular rupture) is associated with skin barrier dysfunction

According to the panelists, there is limited research on the epidermal permeability barrier in untreated skin and after acne treatment. Cutibacterium acne (C. acnes) can initiate and propagate the inflammatory cascade in acne, and “C. acnes proliferation and decreased diversity of the C. acnes phylotype is involved in skin dysbiosis attributing to acne pathogenesis.” Increased sebum production also stimulates the proliferation of C. acnes.

Regarding hormonal initiators, elevated insulin growth factor-1 and androgen levels may increase local pilosebaceous androgenesis, lipogenesis, and increased squalene, fatty acid production, and desaturation. “Together with interleukin-1 β, upregulation and subsequent adaptive immune response activation leads to the development of inflammatory papules, pustules, and nodules,” the authors wrote.

The panelists noted that in acne patients, skin barrier integrity may be compromised, demonstrated by a higher sebum excretion, larger sebaceous glands, and subclinical inflammation. In their first statement, the panelists concluded that it is essential to promote a healthy skin barrier and restore microbiome balance to prevent acne lesion development.

Statement #2: Studies have found an impaired water barrier function (higher transepidermal water loss and conductance value) in acne-affected skin

In their second statement, the panelists mentioned that reduced ceramide levels in acne lesions compared to healthy skin have been observed, which may lead to impaired skin barrier function. One study compared skin barrier function in 36 males with mild or moderate acne to 29 healthy males without acne and found elevated transepidermal water loss (TEWL) and lower conductance in the mild to moderate acne group.²

A second study looked at the correlation between altered ceramide levels and increased TEWL in acne patients and found that all subclasses of ceramide were negatively correlated with increased TEWL, but not with acne symptoms. This study also investigated the ceramide composition of patients with healthy skin and acne-affected skin according to season and found that ceramide levels aggravated acne symptoms, especially in the winter.³

The panelists concluded that “Inherent structural or functional epidermal barrier issues in acne must be addressed therapeutically, especially as certain acne medications can alter some epidermal properties.”

Statement #3: Common ingredients in topical acne products (eg, BPO and retinoids) may irritate the skin

BPO, tretinoin, adapalene, tazarotene, clindamycin, and erythromycin are commonly prescribed topical acne therapies with proven efficacy, but in some patients, they may cause unwanted irritation. These topical therapies can disrupt the skin barrier and elevate TEWL levels, therefore causing irritation and xerosis.

For example, “Topical retinoids may induce acanthosis, corneodesmolysis, and dyshesion of the upper epidermis resulting in erythema and enhanced desquamation,” said the panelists.

The panelists recommend using skin care products that contain lipids such as ceramides to manage barrier disruption often associated with prescription acne treatments. The panelists also mentioned effective topical anti-androgen and systemic anti-androgens, such as clascoterone cream 1%.

Statement #4: Some systemic acne therapies can induce epidermal alterations that disrupt the epidermis's physiological functions, leading to dryness and erythema

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According to the panelists, “The targets involved in acne are the sebaceous glands, infundibular keratinocytes, hair follicles, and organs such as the adrenal gland, ovary, and brain. Acne treatment should address inflammation, sebogenesis, keratinization, relevant bacteria, and mechanisms involved in scarring.”

When recommending acne treatments, clinicians should be aware of the psychosocial and physical effects of acne. A prompt diagnosis and starting patients quickly on a treatment plan may help prevent emotional stress and possible sequelae such as post-inflammatory hyperpigmentation (PIH) and scarring.

Informing patients about acne-related PIH and scarring can help promote treatment and maintenance therapy adherence.

Statement #5: Ceramide-containing cleansers and moisturizers, used as an adjunct to acne treatment, have improved the skin barrier function and reduced irritation

In their final statement, the panelists emphasized the importance of educating patients about the role of inflammation in acne and reducing inflammation. Clinicians can also explain to their patients that decreased face washing and avoiding topical alcohol, abrasive scrubs, and rubbing the skin may prevent irritation and inflammation.

Despite skin type, cleansers and moisturizers should be non-comedogenic and should complement prescription therapies by providing hydration and promoting a healthy skin barrier. “Daily use of fragrance-free, non-irritating, and non-comedogenic cleansers, moisturizers, and sunscreen may reduce inflammation, xerosis, erythema, and photosensitivity resulting from topical or oral acne treatments,” the panelists wrote.

A successful clinical outcome of clearing acne requires adherence, which is often complicated by skin irritation, dryness, burning, and peeling. According to the panelists, incorporating ceramide-containing skin care into a prescription acne regimen can help improve patient adherence and outcomes.

Conclusion

The panelists noted that their literature found no specific clinical studies comparing various skin care products and that their recommendations are based on their clinical experience and opinions.

“Skin care is a necessary part of acne treatment and could enhance treatment adherence. Skin care products containing lipids such as ceramides play an important role in monotherapy, adjunctive, and maintenance treatment, although further research on their role in acne is recommended,” the panelists concluded.

References

1. Schachner LA, Alexis AF, Andriessen A, et al. Insights into acne and the skin barrier: optimizing treatment regimens with ceramide-containing skincare. J Cosmet Dermatol. 2023;00:1-8. doi:10.1111/ jocd.15946.
2. Yamamoto A, Takenouchi K, Ito M. Impaired water barrier function in acne vulgaris. Arch Dermatol Res. 1995;287:214-218.
3. Pappas A, Kendall AC, Brownbridge LC, Batchvarova N, Nicolaou A. Seasonal changes in epidermal ceramides are linked to impaired barrier function in acne patients. Exp Dermatol. 2018;27:833-836