Dermatology Weekly Flash Briefing – Do you know why dermatologists recommend anti-bacterial face wash for acne to acne-prone individuals? Are you confused as to why some individuals who do not seem to care about washing their face, yet never get acne? In this flash briefing, Dr. Teo Wan Lin shares on the importance of skin hygiene for acne sufferers & the role that bacteria plays in acne pathogenesis. She covers the main categories of antibacterial active ingredients present in facial cleansers: synthetic vs natural, as well as the pros and cons for each.
Ep 14: Antibacterial Face Wash for Acne -Fact or Fad?
Hi guys and welcome to this week’s dermatology flash briefing. We’re going to talk about the role of bacteria and dissecting whether or not an antibacterial face wash for acne is a fact or fad.
Synthetic active ingredients in antibacterial face wash for acne
On the topic of the relevance of antibacterial cleansers in the treatment of acne. There are 2 main categories of antibacterial active ingredients present in face wash for acne. The first category would be that of antibacterial ingredients derived from a synthetic source. Triclosan is a chemical that has antiseptic and antibacterial properties. For the last decade, it has been added to a variety of personal care products including hand soaps, cosmetics and toothpaste.The key thing here is that whenever you are using a topical product, in this case Triclosan, you can absorb small amounts via the skin.
In 2017 the FDA came up with a declaration that Triclosan is not generally recognized as safe nor effective as an antiseptic product that’s intended for use in health care settings. It also banned over-the- counter consumer antiseptic wash products containing Triclosan.Their basis for the ban was that the manufacturers weren’t able to prove that Triclosan is safe for daily use over a long period. This is based on some findings in research. For example, that Triclosan can alter hormonal regulation in animals, and can lead to antibiotic resistance. It may even be harmful to the immune system.
Triclosan is not an essential ingredient
The key thing is that Triclosan isn’t an essential ingredient. Even in toothpaste, where it was previously used as an active ingredient to prevent gingivitis. From a dermatological perspective, if you are using a gentle soap that forms a lather which you can rinse off with water; you can also maintain a healthy skin microbiome in an equivalent way. This is as opposed to having to rely on an active ingredient in a face wash for acne that directly kills bacteria. This is with regards to general cleansing of the skin, not specifically targeted at the treatment of acne.
There are a few traditional synthetic chemicals that are beneficial in the treatment of acne. In this case, the importance of cleansers shouldn’t be underemphasized. Ingredients in traditional face wash for acne such as benzoyl peroxide and salicylic acid contain Triclosan. These ingredients appear in literature to have the best efficacy profile in individuals suffering from acne. However, these are mostly European studies in temperate countries. Nevertheless, the key here is that chemical synthetic agents have the ability to inhibit bacteria growth. As we mentioned, if you are acne prone, there is a concern with the bacteria present in your skin. So having an additional active ingredient that can treat this bacterial overgrowth in acne is a bonus.
Instead, medical grade honey
I prefer to use an alternative – medical grade honey cleansers. Medical grade honey has been used in the last decade in advanced wound dressings. Because of its innate ability to modulate the immune cells and mitigate inflammation. Additionally, it also has antibacterial and antifungal effects. It also functions as a humectant, meaning that it traps water under your skin, preventing transepidermal water loss.
Let me touch on how that is more relevant for patients who suffer from acne. One of the most common problems experienced with the use of synthetic chemical ingredients would be that of skin irritation, dryness and redness. It’s easy for a non-clinician to say that for treatment of acne, you can use salicylic acid or benzoyl peroxide because it dries up the pimple. In reality, the clinician in the case of acne, is a dermatologist. We will often notice that it is very common to have irritant contact dermatitis developing because of the astringent nature of these active ingredients.
Factors that contribute to acne
Acne itself is multifactorial in terms of its origin. So it’s not as straightforward as it being caused by oil or bacteria alone. Hence, killing all the bacteria or removing all the oil will not get rid of the acne. If you remove all the oil on the skin, you could still have acne. This is because of the underlying inflammation that predisposes to microcomedone formation under the skin. Subsequently, when it’s visible, you will get whiteheads and blackheads that are closed and open comedones respectively. More than that, the epidermal barrier can be disrupted. A common complaint from individuals with acne- prone skin is that they also have dry skin at the same time. How is that possible? The truth is that both oily and dry skin is very likely caused by the individuals’ acne treatment.
Acne and the skin microbiome
I also want to share about the value of normalizing your skin microbiome in acne patients. We mentioned that a gentle cleanser is able to emulsify the dirt, oil, grime and bacteria. Rinse it off with water and you will have a fairly clean skin microbiome. The key here in acne patients, and of course this has to be fully borne out by studies as well, is that acne-prone individuals may actually find that the bacteria proliferates more on their skin. This is because of the nature of genetics. And, because of the type of oil that they produce – the physical, chemical properties of the sebum.
Having a cleanser that has a residual effect – after you physically rinse it off with water – if it can continue acting on your skin, inhibiting overgrowth of pathogenic bacteria, then you’re certainly making progress in terms of treating and preventing acne flare ups.
Botanical active ingredients in antibacterial face wash for acne
There is value in using botanical anti-inflammatory acne preparations. This is increasingly evident in a post-covid world where we find that we can’t treat maskne topically with our traditional acne creams. For example, those containing the irritating ingredients benzoyl peroxide and salicylic acid, which bleaches fabric and dries up your skin. All these become very irritating under occlusion. In terms of the botanical actives that have shown promise in the treatment of acne; chlorella vulgaris, which is derived from an algae extract, has a multimodal effect on the treatment of acne papules. Its mechanism of action is predominantly via sebum control and being able to suppress inflammation.
Berberine, with origins in traditional Chinese herbal medicine, has been proven in a few cell and clinical studies to treat acne via the following mechanisms. First, it is through the hormonal regulation aspects. We know that individuals who suffer from acne may be extra sensitive to the effects of the circulating male hormone that is present also in females – testosterone. They are more sensitive to its effects on sebum production, hence, triggering acne. Berberine intercepts this pathway. It also helps with mitigating inflammation, and is a potent antioxidant. Finally, it can help to minimize post-inflammatory erythema – which is the redness that arises from inflammation. Subsequently, reducing post-inflammatory hyperpigmentation, a form of acne scarring.
Why do some individuals who do not seem to care about washing their face, never get acne?
The true conundrum in the role bacteria has to play in acne pathogenesis is this. If you do not have the genetics for developing acne, even if you have poor hygiene, you very likely will not develop acne. This is not to say you won’t develop other types of skin conditions or skin infections. But, generally speaking, it will be individuals who have a genetic predisposition to acne-type inflammation that find that their acne is aggravated by poor hygiene. There is a substantial role that this bacteria C. acnes, previously known as P. acnes, plays in the development of acne. When you do the typing of the bacteria present on an acne sufferer’s skin, you’ll find that there is a predominant concentration of the C. acnes bacteria on the skin’s surface.
The importance of skin hygiene in acne
In terms of hygiene in somebody who is suffering from acne, can it make a difference to their acne treatment? The answer is a resounding yes. But, will we go to the extent to say that the direct cause of your acne is from dirty makeup tools and brushes? Well, it is not scientifically accurate to say that it is the direct cause of your acne. Because, as we said before, you have to have a genetic predisposition to acne. But if we did a study, you’ll find that regardless of genetic predisposition, everyone will develop acne if they use dirty makeup tools.
I think the important focus here should be on the healthy balance of bacteria on the individual’s skin, and how, if you are acne-prone, there may be a change in your skin flora, which is consistent with what we have spoken of before in terms of the skin microbiome.
The role of bacteria in acne
If you are going to be using dirty makeup tools on existing acne-type skin where you have papules and pustules, these will get infected with the surface bacteria. It may or may not be from these makeup tools, but if there is a high bacteria load on these tools, if somebody with existing acne bumps uses it on their skin, the comedones, for example, will get infected. That’s when you’ll get the angry, red papules and nodules. If those are persistently developing into painful cysts, that requires treatment with oral medication. If the cysts don’t resolve, you may have to inject intralesional steroids to bring down the size of the cysts, and to reduce inflammation.
That’s it for this week’s flash briefing on my podcast Dermatologist Talks: Science of Beauty. You can follow me on instagram @drteowanlin. Remember to follow us for the latest podcast updates, on Spotify, Apple Podcasts, or wherever you get your podcasts.
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