Years ago, I served as the scientific spokesperson for Clinique, an Estée Lauder brand. As such, I was occasionally involved in the training of Clinique’s skin care experts—the persons dressed in white lab coats, manning Clinique counters in department stores. The training goal was to help the skin care experts identify their customers’ skin problems and to select the most appropriate products to improve the conditions of their skin. During one of these sessions, I was asked what should be given to a customer with severe acne. My answer was immediate and uncompromising: “To a customer with severe acne, you give the address of a good dermatologist.”

As a matter of fact, acne is a problematic pathology that can affect the skin and the psyche of the patient up to unbearable limits. The Webster Dictionary succinctly defines acne as one of the several inflammatory diseases involving the oil glands and hair follicles of the skin. This definition allows one to understand the large number of different manifestations of the disease. It also underscores the lack of precision associated with the term “acne.” This inaccuracy leads laypersons to improperly use the word acne, so that there is often a confusion when people speak of acne because the same word is used for things as different as acne, acneic pathologies, cosmetic acne and the like.

Acne in Medicine

“Real” acne, if I dare say so, can manifest itself in different ways: acne vulgaris, acne conglobate and nodular acne are major acneic-type diseases.

Acne vulgaris is the acne we all think about—and it can be quite severe. According to Jonette E Keri¹ it is characterized by “the formation of comedones, papules, pustules, nodules and/or cysts as a result of obstruction and inflammation of the pilo-sebaceous unit. Acne develops on the face and on the upper trunk. It most often affects adolescents.”

Let us recall here that a papula is a small, raised solid swelling, typically inflamed but not producing pus, whereas a pustula is a solid swelling with a white or yellow pus-filled tip, while a nodule is a general term used to describe any lump underneath the skin that’s at least one centimeter in size. A cyst is a sac that may be filled with air, fluid or other material. Let us also recall that, as defined by JE Keri¹ “comedones are sebaceous plugs impacted within follicles. They are termed open or closed depending on whether the follicle is dilated or closed at the skin surface. Plugs are easily extruded from open comedones but are more difficult to remove from closed comedones. Closed comedones are the precursor lesions to inflammatory acne.”

In the current lay language, open comedones are called blackheads and closed comedones are called whiteheads.

Acne vulgaris is treated with a panoply of topical or systemic drugs such as retinoic acid. Retinoic acid is a photosensitizer and a teratogenic agent. It must be administered under medical surveillance. When the patient is a female potentially able to bear children, systemic retinoic acid has to be administered together with oral contraceptives.

Acne conglobata is an unusually severe type of acne characterized by numerous comedones and large abscesses and cysts that occur on the back, on the buttocks, on the chest, forehead cheeks and shoulders. Acne conglobata provokes scar formation and body disfigurement. It can be treated (with partial success) using a CO₂ laser in combination with topical tretinoin therapy.

Nodular acne is a severe type of acne characterized by the development of nodules deep under the skin. Nodules begin to develop when the bacterium Propionibacterium acnes (also called Cutibacterium acnes) is trapped in a clogged pore. They become visible as red bumps that do not have a whitehead or a blackhead at the center. These nodules are very painful and can last for months. Dermatologists treat Nodular acne with isotretinoin and antibiotics. Remember that isotretinoin is teratogenic and women treated with this drug must be administered oral contraceptives (birth control pill).

“Non-Acne” Acne (Acne-like Pathologies)

Steroid acne, occupational acne and fungal acne are names of acne-resembling diseases that have been named in such a way to recall the possible etiological origins; that is, associating the word acne to a possible reason for its onset.

For instance, steroid acne is the result of an adverse reaction to corticosteroid, characterized by the appearance on the face and chest of small and firm pink papules as well as comedones.

Occupational acne is an inflammation of the sebaceous glands that occurs when chemicals (often those encountered in the workplace) clog the pores and cause an unwanted accumulation of sebum. These chemicals can be coal tar derivatives, insoluble oils for cutting and stamping sheets of metals, chlorinated hydrocarbons or other industrial-use products. Occupational acne disappears when the cause is removed.

Fungal acne is not acne. It is a folliculitis due to the overgrowth of a bug called Malassezia folliculitis or Pityrosporum folliculitis, that in its manifestations look pretty much the same as regular acne.

Cosmetic Acne

A totally different scenario presents when we speak of cosmetic acne. A personal experience helps illustrate my point. One morning, years ago, when I was still working in Long Island, I was awakened by my teenager daughter’s scream. I ran to her room and found her in tears, contemplating a pimple (a tiny little pustula) in the middle of her forehead. There was nothing to discuss: she demanded immediate action. I diluted some bleach in a doll’s thimble and applied the resulting solution on her forehead for a few minutes. The bleach worked miracles: the interior of the pimple was drained out and the pimple disappeared within hours.

Of course, bleach is not an appealing cosmetic ingredient, and is hardly suitable for topical applications in skin care. But it worked and for years thereafter I tried to find ingredients able to drain pimples as efficiently as diluted bleach or hydrogen peroxide, while being easier to formulate. So, every time we had a supplier presenting raw material with potential draining capabilities, I tested the formulations with my daughter to check their actions against pimples. Sometimes her judgement was definitive: “Your stuff works against my acne.” She called it acne, but it was not real acne. It was not severe acne, nor moderate acne. It was what we call “cosmetic acne” and has more of an aesthetic than a medical reason to worry about.

As recently pointed out^2,3 a new aspect of acne, that became of importance during the pandemic, is “maskne.” Maskne, or mask acne, is a problem that needs to be tackled. People concerned with not spreading possibly harmful microorganisms (such as health workers or people afraid to have a respiratory disease such as covid-19) do wear face masks and this can cause breakouts and sensitivity on the face. Wearing a mask may be a necessity; therefore, not wearing a mask is not an option. As such, new approaches are needed to prevent blemishes and irritation while still allowing consumers to wear masks and this adds to the difficulties in caring for acne.

The sad truth is that the etiology of acne is unknown. These difficult words mean that we still do not know the real cause(s) of acne. The more so for cosmetic acne. As it is the case for many other acne pathologies, cosmetic acne happens primarily during puberty and adolescence and sometimes during adulthood. We know that it is associated with the burst of sexual hormones at adolescence (but many adolescents do not have acne) that it is associated with excess sebum (but many oily skins do not experience acne). We know that it is associated with the proliferation of bacteria such as Propionibacterium acnes (but P. acnes is normally resident on our skins even in the absence of acne) and all these things make pimples appear and trigger an inflammatory process. Many myths exist to causally correlate acne with eating behaviors or else, but none are true.

This is to say that we are still searching for the real causes of acne, as well as of cosmetic acne, without much success.

It has recently been pointed out that under the effect of ultraviolet radiation, lipids in the sebum can be peroxidized. Peroxidized lipids are much more viscous than natural sebum and they can clog pores. In clogged pores, anaerobic bacteria; i.e., bacteria that grow only in the absence of oxygen, such as P. acnes, have a greater chance to grow and multiply, thus giving rise to whiteheads and inflamed pimples. Since sebum secretion is hormone-dependent and since hormone bursts are frequent in puberty, this might provide one possible explanation for the onset of acne in hormone-drenched skins.

As we have seen, acne can be a serious disease, for which one needs medical care, and this is beyond the scope of cosmetic treatments. Oral and topical administrations of retinoic acid are sometimes used to treat pathological acne. The problem is that retinoic acid has serious side effects. It is very irritating and photosensitizing when applied topically on the skin and, when taken orally, retinoic acid is teratogenic; that is, it provokes malformations of the fetus when the patient is pregnant.

Regulatory Woes

How do we treat cosmetic acne? That is not easy because scientific research has not yet found the reasons for its onset, and the principal culprit for failing research is the legislator. In the US, a product can be labelled as anti-acne as long as it contains salicylic acid or benzoyl peroxide above a defined threshold, irrespective of the existence of clinical results proving that the product is indeed efficient. Products that do not contain a minimum amount of salicylic acid or benzoyl peroxide are often marketed as anti-blemish.

In the absence of a legislative demand for clinical proof—proof that is required for the claims of sun protection, for instance—the skin care industry often neglects to search for a real treatment. It confines itself to the addition of ingredients acting on collateral aspects, such as redness, oiliness and dryness. Yes! Acneic skin is oily AND dry. Anti-angiogenic materials reduce the formation of blood vessel and for some reason have been used to reduce pimple-associated redness, which is the result of the dilation of already existing blood vessels! Ingredients with enticing names such as shark cartilage, epigallocathechin gallate or the red pigment from saw palmetto, have been added to anti-blemish products with questionable efficacy.

Cosmetic acne can be efficiently tackled by targeting the visible symptoms. Pimples can be addressed with mild exfoliators such as salicylic acid and activators of stratum corneum proteases, applied together with draining materials. Redness can be addressed with anti-inflammatory agents. The side effects of inflammation can be tackled with antioxidants such as vitamins C and E, and with inhibitors of matrix metalloproteases, as well as with energy boosters such as vitamin B3. Oiliness can be mitigated with appropriate inhibitors of sebum production; dryness can be alleviated with efficient moisturizers. Pore clogging can be limited by using scavengers or inhibitors of the production of singlet oxygen, a UV-generated reactive oxygen species that can peroxidize sebum with high efficiency. Comedones are easily extruded, at least partially, by good astringents, and their black extremities can be whisked off. P. acnes can be eliminated by using post biotics that inhibit its growth or by prebiotics that favor the growth of saprofite, harmless micro-organisms able to outgrow P. acnes.

Treating cosmetic acne seems, therefore, within reach; as long as the selection of specific ingredients is the consequence of rigorous clinical tests. As the Brits say, the proof is in the pudding! 

References

1. Keri JE (2022) The Merk Manual, Professional Version, Accessible on the web.
2. Cosmetic & Toiletries, Unmasking “Maskne,” Afternoon Newsletter, 10-5-2022.
3. Giacomoni P (2020) Global Pandemics Renews an Interest in Face Masks. Happi, September 2020.

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Paolo Giacomoni, PhD
Insight Analysis Consulting
paologiac@gmail.com
516-769-6904
 
Paolo Giacomoni acts as an independent consultant to the skin care industry. He served as Executive Director of Research at Estée Lauder and was Head of the Department of Biology with L’Oréal. He has built a record of achievements through research on DNA damage and metabolic impairment induced by UV radiation as well as on the positive effects of vitamins and antioxidants. He has authored more than 100 peer-reviewed publications and has more than 20 patents. He is presently Head of R&D with L-Raphael Beauty, Institute, Geneva, Switzerland.