Myth: Moisturizers Make Acne Worse in Patients With Oily Skin
Excessive sebum production can lead to oily skin that appears greasy and shiny, which contributes to the development of acne on the face. Acne patients with oily skin may be deterred from using moisturizers out of fear that their condition will worsen, yet therapeutic moisturizers have been shown to maintain hydration and overall integrity of the stratum corneum.
In a study of patient experiences with oily skin, 68% (n=37) of participants said their skin felt unclean, dirty, or grimy. Some participants noted a feeling of having clogged pores or an additional layer of skin, and others reported that their skin felt oily or greasy to the touch. The study also reported that participants with oily skin felt self-conscious, which impacted their daily life. These domains also are affected by having acne.
In the same study, 18% (n=10) of participants reported washing their face 6 to 15 times per day, 50% (n=27) washed their face 3 to 5 times per day, and 42% (n=23) washed their face 1 to 2 times per day. Instead of applying heavy moisturizers, acne patients with oily skin may feel the need to constantly wash their face. Gentle face washing is recommended to help improve and prevent acne, but patients who wash their face excessively are at risk for skin barrier impairment and development of dry skin.
Acne patients can use noncomedogenic moisturizers to prevent and alleviate skin irritation and soothe the skin by slowing the evaporation of water. Many moisturizers on the market claim to be suitable for acne treatment and may independently contribute to improving the signs and symptoms of acne. It is important for dermatologists to direct patients with oily skin to oil-free moisturizers containing ingredients such as dimethicone, which is known to reduce transepidermal water loss without a greasy feel and contains both occlusive and emollient properties. Dimethicone is suitable for use in patients with acne and sensitive skin and is noncomedogenic and hypoallergenic. Many oil-free moisturizers also contain certain metals and botanical extracts, such as aloe vera and witch hazel, that are known to have anti-inflammatory and skin-soothing properties. Some liquid face cleansers also moisturize, which may be all that is needed in patients with oily skin.
It also is important to inform patients with oily skin that common acne treatments such as benzoyl peroxide, retinoids, salicylic acid, and oral isotretinoin commonly cause dry skin or irritation, leading to barrier disruption in the stratum corneum and subsequently causing increased transepidermal water loss and inflammation. Concomitant use of noncomedogenic moisturizers can enhance treatment efficacy, alleviate dryness, and improve skin comfort in acne patients who are taking these medications.
An often forgotten element of acne vulgaris is that it is in fact a disease of barrier dysfunction and disruption. As mentioned above, many of the medications used to treat this chronic inflammatory disease are either directly cytotoxic to keratinocytes (benzoyl peroxide) or alter the thickness and composition of the stratum corneum (retinoids), impairing its protective functions. The inflammatory cascade associated with acne itself can impair the barrier, synergizing with the array of aforementioned medications. Both etiological factors disrupt an often overlooked yet crucial component of the skin barrier, the cutaneous microbiota. The altered landscape, or petri dish if you will, unhinges the balance between the >500 species of organisms living in harmony on the skin, decreasing bacterial diversity and facilitating the overgrowth of specific organisms, here specifically certain types of Propionibacterium acnes, which contribute to the ongoing inflammatory cascade. If that's not enough, sebum, which is certainly in excess in acne, contributes very little to barrier function and skin hydration but can be used to cause a different form of disruption by P acnes, which when converted into short-chain fatty acids can impair cutaneous immune tolerance ultimately creating, you guessed it, more inflammation (thank Dr. Rich Gallo for tying this all together). All in all, the barrier is a mess, highlighting the need for barrier repair with a moisturizer to restore the "balance" on every level: Repair and replace the stratum corneum, restore the tools for the right bacteria to grow (water, carbs, lipids, etc). Moisturizers are a must in acne!
—Adam Friedman, MD (Washington, DC)