Acne, Anti-acne Therapies and

Epidermal Barrier Functions: The Role

of Moisturizer as Adjuvant Treatments

Lilik Norawati Ashadi

RSPAD Gatot Soebroto, Jakarta
 Disclosure

This review was sponsored by PT Soho, the

propietor and distributor of the tested product
“Noroid lotion”
 Introduction
• There are several different medications for the treatment
of acne vulgaris (AV), both topical and systemic
• One of the major limitations of topical therapies for AV
is the relatively high potential for cutaneous reactions
characterized by signs (erythema, dryness, roughness etc.)
and symptoms (stinging, burning, etc.) and may lead to
nonadherence and thus treatment failure
• These reactions can result from direct effects of active
ingredient or acne itself leading to epidermal barrier
damage
 Skin barrier function

A normal SB is a primary function of the epidermis

• Regulates epidermal water content & the amount of
water loss
• Neutralize exogenous oxidant damage through an
innate skin anti-oxidant system
• Prevent or limit skin infections with the actions of
antimicrobial peptides
 Skin barrier alteration
Several skin diseases are characterized by a a varying
degree of SB dysfunction:
- Atopic eczema
- Ichthyosis
- Psoriasis

SB alteration could be acquired:

Acne treatment and in particular oral retinoid can alter
SB function in treated patient
 Skin barrier alteration during
systemic and topical acne treatments
Oral isotretinoin

• Dose dependent
• These alteration appear to be related to epidermal
dyscohesion and sebo-suppressive effects
• Commonly involve facial, acral, mucosal (eye, nose
and lips) sites
• Characterized mainly by xerotic and desquamative
changes
Benzoyl peroxide

• Causes xerosis and skin irritation

• Induces damage to the stratum corneum lipid bilayer →
TEWL ↑ & impairment of epidermal antioxidant
potential

Topical retinoid

• Induces ‘retinoid dermatitis’: erythema, scaling,

desquamation → SC thickness ↓ → alteration in
permeability barrier
Dry skin and skin irritation related to topical acne treatment
Skin barrier function in acne patients

• Cholesterol, ceramides, and fatty acid → important

components of lipid bilayers
• Ceramides play a crucial role in the stratum corneum
structure and the regulation of skin barrier
homeostasis
• In acne affected skin, the barrier function is impaired
and decreased water binding leads to a decrease in
skin moisture and a reduction in skin surface lipids
(ceramides)
• Phytosphingosine occurs naturally in the stratum corneum
as a part of the major fraction of ceramides → it plays a
crucial role in permeability barrier function and cutaneous
antimicrobial defense

• In acne affected skin: phytosphingosine is depleted →

leading to impaired skin barrier, inflammation, and
infection → lead to comedo formation (since barrier
dysfunction is accompanied by hyperkeratosis of the
follicular epithelium)
Skin barrier dysfunction in acne-affected skin
 Moisturizers for acne

• Moisturizers can overcome the side effects of dryness and

stinging caused by acne therapy → improve tolerability by
decreasing the dryness and stinging sensation associated
with barrier disruption
• The ideal acne moisturizers: non-comedogenic, non-
acnegenic, hypoallergenic, nonirritating, and is compatible
with the patient’s treatment regimens
• The general recommendation is to use water-based and
non-greasy moisturizers, and should be applied initially
before other topical agents
Journal of Cutaneous and Aesthetic Surgery 2016;9:85-92
Benefits of moisturizers for acne
Ceramide-containing moisturizer for acne:
1. Moisturizers in acne patients help repair the defective
moisture barrier function, help prepare the skin for treatment,
and protect against further damage.

2. When moisturizer have incorporation of ceramides,

components of the intercellular lipids, they are capable of
protecting the skin. These moisturizers replenish ceramides
and help repair the skin barrier.

3. Both in vitro and in vivo, the ceramide-containing moisturizer

showed excellent clinical results in acne management →
enhancing or complementing existing acne therapies
JCAD 2014;7:40-48
Benefits of ceramides containing moisturizer for acne
 Ceramide and pseudo ceramide
• Ceramide can be extracted from natural animal sources,
but this process is lengthy and expensive with limited
availability.
• There are concerns about the toxicity and the risk of
transmissible infections, such as bovine encephalopathy,
from bovine derived source.
• Hence, synthetic pseudo ceramides, which have been
developed and used successfully in skin barrier repair
therapy, have a good safety profile and are less expensive
than natural ceramides.

Dermatology and Therapy 2014;4:83-92

 Efficacy evaluation of unique skincare
product containing pseudo ceramide

Journal of Cosmetics, Dermatological Science and Applications 2014;4:250-258

Improvement of dryness and barrier function by external use of

ceramide and ceramide analogues (pseudo ceramide) in patients have
been investigated, and a superior moisturizing effect and improvement
of the barrier function have been clarified.

In addition, a technique to disperse pseudo ceramide in a lamellar

structure in water has recently been developed, for which a high and
persistent moisturizing effect can be expected because the lamellar
structure continuously retains water between the lamellar layers.
CASE STUDY
 Aim of this study

To assess the cutaneous tolerability, overall

performance, and cosmetic acceptability of pseudo
ceramide-containing moisturizer (Noroid®) as an
adjuvant skin care regimen in the management of acne.
 Materials and methods

• Multicenter, open-label retrospective questionnaire-

based survey designed to assess the cutaneous
tolerability, overall performance, and cosmetic
acceptability of pseudo ceramide-containing
moisturizer (Noroid®).
• Four doctors from different clinic (Bogor, Depok,
Cibinong, Jakarta) were maintaining the patient’s
clinical record including the sensorial profile of
cosmetic products.
• Twenty patients of more than 12 years of age with mild
to moderate acne on anti-acne therapy (adapalene and
clyndamycin) along with ceramide-containing
moisturizer, with facial skin symptoms (itching, stinging,
erythema, dryness) and keeping monthly follow up were
included in this survey.

Skin tolerability assessment

Skin tolerability assessment was done by analyzing the

responses from both patients (subjective assessment) and
investigator (objective assessment) during 8 weeks.
Safety assessment

Safety assessment was done by analyzing all the reported

adverse events during the survey period.
 Results

• There was a significant improvement in all parameters of

facial skin tolerability (subjective assessment: itching,
stinging, tightness; objective assessment: dryness and
erythema), overall performance, and cosmetic
acceptability of pseudo ceramide-containing moisturizer
(Noroid®).
• The result of this survey signify that incorporating pseudo
ceramide-containing moisturizer in the management of
acne may help improvement of cutaneous tolerability and
overall patient satisfaction with acne treatment.
 Itching Burning Stinging Tightness

Baseline 16 14 13 20

Day 28 7 6 6 8

Day 56 1 1 1 2

Facial skin tolerability assessment (subjective)

 Erythema Dryness Roughness

Baseline 18 20 16

Day 28 7 4 7

Day 56 1 1 0

Facial skin tolerability assessment (objective)

Treatment improved skin texture 20
Treatment is easy to use 18
Treatment met my needs 16
Allowed them to not miss applications of acne 20
medications
Overall satisfied with treatment 19

Regimen satisfaction at day 56

Before and after 8 weeks treatment
 Conclusions
• A very important reason for nonadherence to acne
treatment is dry skin and irritation
• Dry skin & irritation commonly results from systemic
retinoid and topical acne treatment
• Skin barrier dysfunction may contribute to the signs and
symptoms of acne
• Pseudo ceramide-containing moisturizers may enhance
and complement existing acne therapies
• Adjunctive therapy with pseudo ceramide-containing
moisturizers should be considered in acne-treated patients
Thank You