Addressing the Unmet Need in Acne Management: A Novel Dermocosmetics Guideline Tailored to Asian Patient Subgroups

Abstract

Acne, a commonly treated skin disease, requires control of one’s daily routine for an optimal outcome. As skincare products continue to advance, and with the introduction of dermocosmetics (active cosmetics, functional cosmetics, cosmeceuticals), it is necessary for clinicians to stay updated and give professional guidance. Following a literature review, a panel discussed and, using an online review process, explored the available acne dermocosmetics and convened to develop consensus statements on acne skincare incorporating patient- and treatment-related factors. Recommendations tailored to several distinct patient subgroups, namely, preadolescent acne, adolescent/adult acne, acne with comorbid atopic dermatitis, acne in pregnancy, drug-induced acne, and acne cosmetica, were generated to maximize the use of dermocosmetics in acne management. In adolescent and adult acne, products with active ingredients that mark key aspects of acne pathophysiology are called for; in atopics, agents which protect and restore the skin barrier are primarily considered; and in the preadolescent age group and pregnant and lactating women, the use of acne dermocosmetics should be prioritized as there are limited treatment options. While skincare alone is often sufficient for mild acne and for maintenance, adjunctive skincare can enhance treatment efficacy as well as patient adherence in various settings. This guideline seeks to offer insights into acne dermocosmetics and provide skincare recommendation tailored to Asian patient subgroups.

1. Introduction

Acne is a multifactorial skin disorder (Figure 1) familiar to dermatologists and healthcare professionals [1,2]. While efficacious treatment options are available [3], acne runs a lengthy course of acute bursts and reappearances requiring long-term management [4]. Everyday skincare, including basic routines and utilizing dermocosmetics, is an integral component in acne management [5,6] but is often overlooked.

Dermocosmetics are skincare products with dermatologically active ingredients [7]. Their role varies from a sole measure aimed at maintaining the skin condition to an adjunct, complementing the medical treatment [8]. Increased adherence to acne treatment has been recognized by employing dermocosmetics, likely due to their ability to reduce skin irritation and target the main pathogenic pathways of acne [9,10,11]. Since acne affects diverse populations with different ethnicities, ages, and backgrounds, patients require a tailored approach in skincare. Despite the varying presentation of acne in Asian patient subgroups, established guidelines address skincare in a very general way, recommending low-irritant and non-comedogenic products [12,13].

As skincare products continue to advance, and with the introduction of dermocosmetics, it is necessary for clinicians to stay updated and give professional guidance. This is particularly relevant in South Korea, where a thriving dermocosmetics market and deep-rooted cultural emphasis on skincare exist. This guideline offers insights into acne dermocosmetics and provides skincare recommendations incorporating patient- and treatment-related factors. Our acne management algorithm, which integrates expert consensus on Asian skincare, is tailored to six distinct patient subgroups: preadolescent acne, adolescent/adult acne, acne with comorbid atopic dermatitis, acne in pregnancy/lactation, drug-induced acne, and acne cosmetica.

Figure 1. Acne pathomechanism is complex involving C. acnes, hyperseborrhea, hyperkeratosis, and inflammation (reprinted with permission from Lee et al. [14]).

Figure 1. Acne pathomechanism is complex involving C. acnes, hyperseborrhea, hyperkeratosis, and inflammation (reprinted with permission from Lee et al. [14]).

2. Materials and Methods

A panel of six Korean experts was convened for this study, comprising five dermatologists specializing in acne and one internist. The panelists were selected based on their recognized expertise in acne treatment, their influence within the Korean dermatological community, and their experience with diverse acne patient profiles. One chairperson, an expert in acne and with experience in panel moderation, oversaw the panel selection process and facilitated the meetings.

Two advisory board meetings were conducted: the first on 13 February 2024 and the second on 4 July 2024. During these meetings, each dermatologist presented acne patient subtypes relevant to their specific area of expertise. The chairperson facilitated discussions, ensuring all perspectives were considered and fostering a consensus-building environment. The meetings focused on adapting existing acne treatment algorithms to the specific characteristics of Asian and, more specifically, Korean acne patients. The acne treatment and skincare algorithm was developed through an iterative process, integrating the evidence gathered from the literature review with the expert opinions elicited during the advisory board meetings.

The algorithm considers patient-specific factors (e.g., age, acne severity, skin type) and treatment-related factors (e.g., potential side effects, patient adherence) to provide tailored recommendations. The algorithm was designed to be practical and easily implemented by healthcare providers in clinical settings.

2.1. Literature Review

Prior to the meeting, a literature search was made to identify the current best management strategies for acne, encompassing prescription and non-prescription products, and skincare as monotherapy, adjunctive therapy, and maintenance therapy. Searches on PubMed and Google Scholar were made to retrieve pertinent information from acne guidelines, algorithms, clinical studies, and review articles published in English (2010–2024). A search of relevant terms was conducted, including “acne” plus the following: Asian OR preadolescent OR adolescent OR adult OR atopic dermatitis OR pregnancy OR drug-induced acne OR acne cosmetica OR dermocosmetic OR treatment OR maintenance OR skincare as monotherapy and adjunct OR cleansers OR moisturizers OR skin barrier OR dermocosmetics efficacy OR dermocosmetics safety OR skin irritation OR skin microbiome.

Publications in non-English languages and which did not deal with acne skincare were excluded. Two authors (E.B. and H.S.K.) manually reviewed the references from selected publications for additional resources. Initially, 295 papers were identified. After removing 230 articles which lacked data relevant to acne dermocosmetics and skincare, and taking out 7 duplicates, 58 articles remained.

The panel adopted a two-pronged approach in reviewing acne dermocosmetics:

• A focus on acne dermocosmetics as classified according to their action mechanism (i.e., sebum control, keratolytic, skin barrier and microbiome protecting, anti-inflammatory).
• Evidence level grading (A–D) of dermocosmetic ingredients from existing high-quality reviews (systematic reviews, meta-analyses).

2.2. Expert Consensus and Guideline Development

Through critical discussion and consensus-building, the panel formulated a comprehensive acne management algorithm. This algorithm integrates conventional treatment with evidence-based dermocosmetics recommendations tailored to distinct patient subtypes. The resulting guidance reflects current scientific understanding, prioritizes patient safety, and incorporates practical considerations relevant to the Asian population.

3. Results and Discussion

3.1. Characteristics of Asian Patients with Acne

Asian skin has more melanin than that of a white person, which increases post-inflammatory hyperpigmentation (PIH) risk when inflamed (i.e., acne) or injured (i.e., laser therapy) [15,16]. In addition, Asians are reported to have an elevated neurosensory response [15,17] and weaker barrier strength [18] compared to other ethnicities. Such features lead Asians to display a greater sensitivity and less tolerability to topical agents such as benzoyl peroxide (BPO) and adapalene [19], which limits its use in the population, especially in those with sensitive skin. Among the diverse group of Asians, Northeast Asians (i.e., Chinese, Japanese, and Korean) with skin phototypes III and IV were observed to be more readily irritated by retinoids than Southeast Asians with darker skin (prototypes IV and V) [20,21].

The use of makeup is much sought-after among Korean adolescents. According to a questionnaire survey conducted on 192 middle school students [22], 32.8% replied that they regularly use makeup. Among them, 55.5% answered that their acne intensifies after putting on makeup, which is linked with the frequency and extent of color cosmetic use. Suh et al. also mentioned the influence of color cosmetics in Korean adult acne and recommended using a powder-type color makeup and physical sunscreen for patients [23].

Also notable from the questionnaire study is that among the 106 middle schoolers with acne, 63% claimed to have tried acne dermocosmetics [22]. A study on the treatment-seeking behaviors of Koreans also found that acne individuals favored and initiated nonprescription topicals before visiting a dermatologist [24].

Regarding the acne treatment patterns in Korea, a nationwide study identified that physicians prioritize oral antibiotics, physical treatments, and light-based therapies compared to topical agents in mild to moderate acne [25]. Despite the effort, a global study found 48% of the Asian acne population to have poor adherence to treatment, largely linked with experience of side effects and nonuse of appropriate moisturizers and cleansers [26,27].

3.2. Dermocosmetics

Dermocosmetics is a relatively new term which describes a range of products that have both functionally active ingredients and cosmetic value [28]. Acne dermocosmetics include skin cleansers, moisturizers, and sunscreens which include active ingredients targeting the four main pathogenic pathways of acne (i.e., abnormal sebum production, abnormal keratinization, inflammatory mediator release, abnormal C. acnes colonization) [5,29]. In Asians, dermocosmetics which protect/restore the skin barrier and lighten pigmentation are also much sought after. Figure 2 shows the six pillars of acne dermocosmetics with active ingredients categorized according to their mode of action, while

Table A1. Summary of the active cosmetic ingredients which target the pathogenic pathways of acne.

Ingredients	Study Details	References
Abnormal keratinization Agents
Salicylic Acid (SA)	A randomized controlled trial demonstrated superior efficacy of combined oral isotretinoin (20 mg daily for 16 weeks) and 20% SA peels every two weeks compared to isotretinoin monotherapy in reducing acne lesions in patients with moderate to severe facial acne. This finding supports the inclusion of SA peels as an adjunctive therapy for enhanced efficacy in treating moderate to severe acne.	Kar BR. 2013 [73]
Glycolic Acid	Glycolic acid peels are a simple, inexpensive, and effective treatment for various skin conditions like acne, melasma, and photoaging. This review highlights the importance of proper patient selection and application techniques for optimal results and emphasizes the peel’s versatility and safety for a range of skin types.	Sharad. 2013 [74]
PHYLOBIOMA	Pomegranate seed oil promotes epidermal regeneration (keratinocyte proliferation, epidermal thickening), while pomegranate peel extract supports dermal regeneration (procollagen synthesis, MMP-1 inhibition). These distinct effects suggest potential benefits for overall skin health and indirectly support healthy keratinization.	Aslam MN, et al., 2006 [75]
Linoleic Acid	This study demonstrates that topical application of linoleic acid can significantly reduce the size of acne microcomedones, suggesting a potential role in normalizing follicular keratinization. The observed reduction in microcomedone size after linoleic acid treatment implies an improvement in the follicular environment, likely by influencing lipid composition and reducing abnormal cell cohesion within the follicle. This supports the hypothesis that linoleic acid deficiency may contribute to the disturbed keratinization seen in acne and suggests its topical application could be a valuable therapeutic strategy.	Letawe C, et al., 1998 [76]
Alpha Hydroxy Acids (AHA)	A 10% glycolic acid oil-in-water emulsion significantly improves mild acne, likely by normalizing follicular keratinization through its exfoliating action and by reducing corneocyte cohesion, thus lessening comedone formation. The study showed significant improvement after just 45 days of treatment, with good tolerability.	Abels, et al., 2011 [77]
Retinol-Based Products	This study found that a combination of retinaldehyde and glycolic acid is effective in treating adult acne, even when used alongside other non-retinoid acne treatments. Retinaldehyde normalizes follicular keratinization, while glycolic acid enhances this effect through exfoliation, leading to a significant reduction in both inflammatory and retentional acne lesions. The combination was also well tolerated.	Dreno B, et al., 2009 [78]
Maltodextrine	A dermocosmetic regimen containing maltodextrin and Bixa orellana seed extract significantly improved acne and skin sensitivity, suggesting a potential role for maltodextrin in supporting healthy keratinization, although its precise mechanism requires further investigation.	Kurokawa I, et al., 2023 [8]
Bixa Orellana Seed Extract	This study demonstrates the efficacy of EFFACLAR H ISO-BIOME cream and washing cream as adjunctive therapy in acne treatment. Independent evidence suggests Bixa orellana reduces sebum and hyperkeratinization. The observed improvements in sebum secretion, papules/pustules, hyperpigmentation, and erythema in the study indirectly suggest a positive impact on keratinization processes. Reduced sebum and inflammation create a healthier skin environment, which may promote proper keratinization. Further research is needed to investigate any direct impact of Bixa orellana and EFFACLAR H on follicular keratinization and explore their potential synergistic effects. This would clarify the precise mechanisms by which these ingredients, individually or in combination, address abnormal keratinization in acne.	Kwiatkowska D, et al., 2023 [79]
Lipohydroxy Acid (LHA)	This study showed that a facial serum with HEPES, LHA, and other acids effectively reduces post-inflammatory hyperpigmentation and oiliness in acne. While the study does not detail specific mechanisms, LHA’s keratolytic properties likely contribute to normalized keratinization, aided by HEPES’s pH-stabilizing effects and the other acids’ skin-renewing properties. The combined action improves skin quality and reduces hyperpigmentation, likely by influencing keratinization.	Campos V, et al., 2021 [80]
N-2-hydroxyethylpiperazine- N’-2-ethanesulfonic Acid (HEPES)
Sebum-controlling agents
Niacinamide (nicotinamide)	Topical 2% niacinamide reduced sebum excretion rates in Japanese subjects and casual sebum levels in Caucasians, demonstrating its potential as a sebum-controlling agent. However, the varying effects between ethnicities and sebum measurements warrant further research to clarify its precise mechanism of action.	Draelos ZD, et al., 2006 [81]
	While both Pelargonium graveolens and niacinamide-containing tonics provided sustained sebum reduction, Pelargonium graveolens proved more effective in this short-term study. Further research is needed to understand niacinamide’s long-term impact on sebum control and its specific mechanism of action.	Kozlowska J, et al., 2017 [82]
Zinc	Zinc may decrease sebum production and has antibacterial and anti-inflammatory effects beneficial in acne treatment, but current evidence is limited. More research is needed to confirm its role as a sebum-controlling agent and clarify its mechanism of action.	Brandt S, et al., 2013 [83]
Punica granatum Pericarp Extract (PHYLOBIOMA)	Punica granatum pericarp extract (Phylobioma) is suggested to regulate sebaceous gland activity among other beneficial actions against acne, including modulating the microbiota and reducing inflammation. However, more research is needed to provide specific data and clarify its sebum-controlling mechanism.	Zegarska B, et al., 2023 [84]
Epigallocatechin-3-gallate (EGCG)	EGCG shows promise as an acne treatment by reducing sebum production (via AMPK-SREBP-1 pathway modulation), suppressing inflammation, and inhibiting P. acnes. Clinical trials confirm its efficacy and tolerability, but further research is needed to fully quantify its sebum-controlling effect in humans and explore long-term effects.	Yoon JY, et al., 2013 [85]
Bakuchiol	Bakuchiol shows promise in acne management by targeting multiple pathogenic factors, including sebum production (via 5-α-reductase downregulation), P. acnes proliferation, and inflammation. Clinical trials demonstrated its efficacy, especially when combined with salicylic acid, but further research is needed to quantify its sebum-controlling effects and compare it to other agents.	Chaudhuri RK, et al., 2011 [86]
	This review highlights bakuchiol’s diverse bioactivities relevant to skin health but lacks specific data on its sebum-controlling properties. While its use in acne treatment suggests this potential, further research directly investigating its impact on sebum production is needed.	Mascarenhas-Melo F, et al., 2024 [87]
Fullerene	Fullerene gel effectively reduced inflammatory acne lesions and inhibited sebum production in vitro. While this suggests its potential as a sebum-controlling agent, further research is needed to confirm and quantify this effect in vivo and clarify its mechanism of action.	Inui S, et al., 2011 [88]
Bixa Orellana Seed Extract	A dermocosmetic regimen including Bixa orellana seed extract, used alongside adapalene-BPO gel, significantly improved acne and reduced skin sensitivity in patients with mild to moderate acne. Bixa orellana, known to reduce sebum and hyperkeratinization, likely contributed to these improvements.	Kurokawa I, et al., 2023 [8]
	This study showed that EFFACLAR H ISO-BIOME cream and washing cream, used alongside conventional acne treatments, significantly improved acne severity and reduced sebum secretion, among other benefits. Although Bixa orellana seed extract is not mentioned in this study, its known sebum-controlling properties suggest potential synergistic effects if it were incorporated into similar regimens.	Kwiatkowska D, et al., 2023 [79]
Anti-inflammatory agents
Salicylic Acid (SA)	Salicylic acid treats acne by decreasing sebum production (via AMPK/SREBP-1 pathway downregulation) and exhibiting anti-inflammatory effects (via NF-κB pathway suppression), confirmed by both in vitro and in vivo studies.	Lu J, et al., 2019 [89]
	Salicylic acid peels effectively reduced both inflammatory and non-inflammatory acne lesions in Asian patients. While this suggests potential anti-inflammatory effects, the study lacks direct evidence or mechanistic exploration, warranting further research to confirm this aspect of SA’s action.	Lee HS, et al., 2003 [90]
Niacinamide (nicotinamide)	Niacinamide offers various skin benefits, including anti-inflammatory effects in acne and rosacea. However, the mechanisms behind these effects are not detailed, requiring further research to provide specific data and clarify its role as an anti-inflammatory agent.	Gehring W, et al., 2004 [91]
Zinc	This review positions zinc as a promising, well-tolerated, and cost-effective acne treatment, suggesting that its likely anti-inflammatory properties contribute to its efficacy.	Cervantes J, et al., 2018 [92]
Vitreoscilla filiformis (APF)	A new Vitreoscilla filiformis extract activates cutaneous antioxidant and antimicrobial defenses, potentially via the TLR2 pathway. While this suggests a possible link to anti-inflammatory activity, further research is needed to directly assess and confirm these effects.	Mahe YF, et al., 2013 [93]
Punica granatum Pericarp Extract (PHYLOBIOMA)	Pomegranate extract (PG-E) and its component granatin B exhibit anti-inflammatory properties relevant to acne treatment by decreasing COX-2 expression and prostaglandin E₂ production. Further research on individual PG-E components could clarify their specific anti-inflammatory mechanisms.	Lee CJ, et al., 2017 [94]
	This review explores medicinal plants and their constituents for acne treatment, citing various active compounds with anti-acne properties. However, it lacks specific information on individual plant extracts, like Punica granatum pericarp extract, and their anti-inflammatory mechanisms.	Abozeid D, et al., 2023 [95]
Bakuchiol	Bakuchiol demonstrates significant potential as an anti-inflammatory agent in acne treatment. It inhibits key inflammatory pathways (COX enzymes, iNOS, leukotriene B4, thromboxane B2), effectively reducing inflammatory acne lesions. This multi-pronged approach to inflammation, combined with its action against other acne-causing factors, makes bakuchiol a promising ingredient for comprehensive acne management. Further research directly measuring inflammatory markers would provide even stronger evidence for its anti-inflammatory efficacy.	Chaudhuri RK, et al., 2011 [86]
Panthenol	Dexpanthenol showed protective effects against skin irritation, maintaining better hydration and reducing the severity of contact dermatitis. While this suggests a potential anti-inflammatory role, the study does not directly address inflammation. Further research investigating inflammatory markers and comparing dexpanthenol to known anti-inflammatory agents is needed to confirm its anti-inflammatory properties.	Biro K, et al., 2003 [96]
ProceradTM	This study found a salicylic acid-based dermocosmetic cream (DC-Eff) as effective as benzoyl peroxide in treating acne, but with better tolerability. DC-Eff contains Procerad™ (2-oleamido-1,3-octadecanediol), a ceramide known to reduce blemishes, and Aquaposae filiformis, which restores the skin barrier. While the study does not isolate Procerad™’s specific contribution to the anti-inflammatory effect, its inclusion likely supports overall skin health and improves tolerance, contributing to the observed efficacy of DC-Eff.	Dal Belo SE, et al., 2024 [97]
Licochalcone A	Licochalcone A demonstrated anti-inflammatory properties in vitro by reducing NFκB signaling and PGE2 secretion. A cream containing licochalcone A also reduced shaving-induced erythema in vivo. Further research isolating licochalcone A’s effects would strengthen the evidence for its use as an anti-inflammatory agent.	Sulzberger M, et al., 2016 [98]
Bixa Orellana Seed Extract	Bixin, derived from Bixa orellana seeds, reduced UVB-induced skin inflammation and immunosuppression in mice, suggesting its potential as an anti-inflammatory agent.	Hussaana A, et al., 2019 [99]
LRP THERMAL WATER	This article highlights a moisturizer with selenium-rich postbiotic thermal water and biomass as a potential treatment for atopic dermatitis, improving skin homeostasis and symptoms. While this suggests anti-inflammatory benefits, the abstract lacks specific details on the components (like LRP Thermal Water, if applicable) and their anti-inflammatory mechanisms.	Baldwin H, et al., 2020 [100]
N-2-hydroxyethylpiperazine- N’-2-ethanesulfonic Acid (HEPES)	A facial serum containing HEPES and other acids effectively reduced post-inflammatory hyperpigmentation and oiliness in acne. While this suggests a potential indirect anti-inflammatory benefit from HEPES, likely due to its pH-stabilizing properties, the study lacks direct evidence of its anti-inflammatory mechanisms.	Campos V, et al., 2021 [80]
Shea butter	This review discusses the skin benefits of various plant oils, including shea butter, highlighting their anti-inflammatory and skin barrier repair properties. However, it lacks specific data on shea butter’s anti-inflammatory effects and mechanisms.	Lin TK, et al., 2017 [101]
Antimicrobial agents
Salicylic Acid (SA)	Two modified salicylic acid compounds, 5-nitro acetyl salicylic acid and 5-bromo acetyl salicylic acid, demonstrated antibacterial activity against E. coli and S. aureus without cytotoxic effects. Further research is needed to compare their activity to standard salicylic acid and explore their mechanisms of action.	Al-Salman SJA, et al., 2017 [102]
Zinc	A novel zinc–glucose–citrate complex (ZnGC) exhibited enhanced antibacterial activity against both S. aureus and E. coli compared to zinc chloride, with reduced toxicity. Further research is needed to elucidate the specific mechanisms underlying ZnGC’s improved antimicrobial properties.	Zhang Y, et al., 2021 [103]
Mannose	This study found that mannose-binding lectin (MBL) deficiency is associated with increased sensitization to Candida albicans in atopic dermatitis patients, suggesting MBL’s importance in controlling this microbe. While this highlights the role of mannose in immune defense, further research is needed to explore its potential as a standalone antimicrobial agent.	Belfrage E, et al., 2023 [104]
Vitreoscilla filiformis (APF)	Aqua Posae Filiformis (APF) and Microresyl offer a promising combination for managing skin barrier defects. Microresyl provides direct antibacterial and anti-biofilm action, while APF contributes through immunomodulatory and anti-inflammatory properties.	Trzeciak M, et al., 2023 [105]
Punica granatum Pericarp Extract (PHYLOBIOMA)	Pomegranate extract (PG-E) and its constituent tannins demonstrated antibacterial and anti-lipase activities relevant to acne treatment. Further research is needed to clarify the antimicrobial mechanisms and contributions of individual PG-E components, especially regarding Punica granatum pericarp extract.	Lee CJ, et al., 2017 [94]
Decanediol	Decanediol demonstrates broad antimicrobial activity against several microbes, including P. acnes, and has shown efficacy in improving acne outcomes in a clinical trial. Its mechanism likely involves disrupting bacterial cell membranes.	Sulzberger M, et al., 2016 [106]
Tea Tree Oil	Tea tree oil (TTO), particularly its component terpinen-4-ol, demonstrates broad-spectrum antimicrobial activity against various skin infections and is suggested for treating conditions like acne and seborrheic dermatitis. However, further research quantifying its antimicrobial activity and clarifying its mechanisms of action would strengthen the evidence.	Pazyar N, et al., 2013 [107]
Bakuchiol	Bakuchiol demonstrated potent in vitro antimicrobial activity against various oral pathogens, including S. mutans, with its efficacy remaining stable under diverse conditions. This supports its potential for development into oral health antibacterial agents. Further research should explore in vivo efficacy and synergistic combinations.	Katsura H, et al., 2001 [108]
Octopirox	Octopirox demonstrated broad-spectrum antimicrobial activity in foaming products, with a 0.5% concentration deemed optimal for targeting microorganisms associated with seborrheic dermatitis.	Zaika, S. V, et al., 2020 [109]
Lactobacillus	A Lactobacillus brevis strain isolated from dairy produced a heat-stable, proteinaceous antimicrobial compound effective against various bacteria. Further research characterizing this compound, quantifying its activity, and exploring in vivo efficacy is warranted.	Rushdy AA, et al., 2013 [110]
Benzoyl Peroxide (BPO)	The Faces of Pediatric Acne Project (FoPAP) developed a practical algorithm for treating pediatric acne. This algorithm, based on a consensus paper, clinical case series, the existing literature, and expert experience, provides a structured approach to managing acne across different age groups and severities. It covers everything from initial assessment and diagnosis to treatment, maintenance, and skincare recommendations. Benzoyl peroxide, a potent topical antimicrobial that rapidly kills C. acnes bacteria by oxidizing their proteins, is likely included in the algorithm’s treatment recommendations.	Schachner, et al., 2023 [111]
Bixa Orellana Seed Extract	Aqueous extracts of urucum seeds demonstrated significant antimicrobial activity in this study. This antimicrobial activity, combined with antioxidant and notably effective wound-healing properties in rats, suggests the extract’s potential as a phytotherapeutic agent.	Franklin VA, et al., 2023 [112]
Piroctone Olamine	This study highlights piroctone olamine’s potential as a systemic antifungal agent. Its efficacy against C. albicans in a mouse model of intra-abdominal candidiasis was comparable to that of amphotericin B, a standard antifungal treatment. This suggests that piroctone olamine, already known for its topical antimicrobial properties, might have broader applications in treating systemic fungal infections.	do Couto FM, et al., 2016 [113]
Skin Barrier- and Microbiome-Protecting Agents
Niacinamide (nicotinamide)	Nicotinamide enhances skin barrier function by increasing the biosynthesis of ceramides and other essential lipids in the stratum corneum. This improved barrier function, demonstrated by reduced transepidermal water loss, indirectly supports a healthy skin microbiome by preventing dysbiosis and protecting against pathogens. Topical application of nicotinamide was shown to be effective in increasing ceramide and free fatty acid levels in the stratum corneum.	Tanno O, et al., 2000 [114]
Zinc	A zinc lactobionate emollient cream effectively lowered skin surface pH in atopic dermatitis patients, resulting in improved skin barrier function. This included reduced transepidermal water loss and decreased sensitivity to irritants. A strengthened skin barrier, as facilitated by the acidic pH and zinc’s properties, indirectly supports a healthy microbiome by protecting against pathogens and preventing dysbiosis.	Andrew PV, et al., 2024 [115]
Vitreoscilla filiformis (APF)	This article emphasizes the importance of addressing skin barrier dysfunction and dysbiosis in atopic dermatitis. It suggests that a selenium-rich postbiotic moisturizer can help restore skin homeostasis, improve barrier function, and promote a healthy microbiome, ultimately alleviating AD symptoms. Vitreoscilla filiformis lysate (APF), cultivated in La Roche-Posay Thermal Spring Water (LRP-TSW), acts as a postbiotic, promoting a balanced skin microbiome and reducing AD severity. LRP-TSW itself exhibits prebiotic and probiotic properties, enhancing microbial diversity. An emollient containing both LRP-TSW and APF improved AD symptoms, increased bacterial diversity, and decreased Staphylococcus abundance on affected skin, demonstrating the therapeutic potential of prebiotics in modulating the skin microbiome and improving barrier function in AD. These benefits persisted even after treatment discontinuation.	Baldwin H, et al., 2020 [100]
Mannose	Dermocosmetics play a valuable role in acne management by targeting both acne pathophysiology and skin barrier function. Ingredients like niacinamide, retinol derivatives, and salicylic acid address acne-specific concerns, while ceramides, glycerin, thermal spring water, and panthenol support a healthy skin barrier. This strengthened barrier, in turn, promotes a balanced microbiome and minimizes irritation from acne treatments. While mannose is mentioned as a potential barrier-supporting ingredient, further investigation is needed to understand its specific role.	Kurokawa I, et al., 2023 [8]
Shea butter	This study examined the effects of various lipids on surfactant-irritated skin. While canola oil and its sterol-enriched fraction showed promise in reducing irritation and improving barrier function. This highlights the importance of lipid composition in topical formulations for barrier repair and suggests that further research is needed to understand the role of shea butter in skin barrier and microbiome health.	Loden M, et al., 1996 [116]
Glycerin	Glycerol plays a crucial role in maintaining skin hydration and barrier function, as demonstrated by its ability to correct defects in AQP3-deficient mice. By restoring hydration and promoting barrier recovery, glycerol indirectly supports a healthy skin microbiome. This reinforces the importance of glycerol as a skin barrier- and microbiome-protecting agent.	Hara M, et al., 2003 [117]
Ceramide	Phytosphingosine-based ceramides are essential for maintaining a healthy skin barrier, particularly in atopic skin. Replenishing these ceramides topically, along with cholesterol and free fatty acids, and boosting their biosynthesis with ingredients like niacinamide and lactic acid can improve barrier function, indirectly supporting a balanced microbiome and alleviating atopic skin conditions.	Mijaljica D, et al., 2024 [118]
Panthenol	A cream containing panthenol, prebiotics, and probiotic lysate demonstrated significant improvements in sensitive skin symptoms and objective measures of skin barrier function. By strengthening the skin barrier, this combination indirectly supports a healthy microbiome, making it a promising approach for managing sensitive skin.	Zhang X, et al., 2024 [119]
LRP THERMAL WATER	La Roche-Posay Thermal Spring Water (LRP-TSW), with its prebiotic and probiotic properties, promotes a balanced and diverse skin microbiome. This, in turn, indirectly supports skin barrier integrity, making LRP-TSW a valuable agent for managing inflammatory skin conditions and overall skin health.	Zeichner J, et al., 2018 [120]
Punica granatum Pericarp Extract (PHYLOBIOMA)	Pomegranate extracts, rich in antioxidant polyphenols, show promise in protecting the skin barrier from oxidative damage and supporting a healthy microbiome through anti-inflammatory and antimicrobial properties. More human studies are needed to confirm these effects and explore the potential of specific extracts like PHYLOBIOMA.	Dimitrijevic J, et al., 2024 [121]
Epidermal Growth Factor (EGF)	Topical EGF shows promise in treating atopic dermatitis by improving skin barrier function and modulating immune responses. The strengthened barrier, along with reduced inflammation, indirectly supports a healthy skin microbiome, making EGF a potential therapeutic agent for AD.	Kim YJ, et al., 2018 [122]
Anti-Pigmentation/Mark Agents
Niacinamide (nicotinamide)	The combination of 4-hexylresorcinol and niacinamide demonstrated superior efficacy in reducing hyperpigmentation and improving skin tone compared to niacinamide alone. This synergistic combination, by targeting multiple pathways in melanogenesis, offers a promising and safe alternative for treating hyperpigmentation and signs of aging.	Shariff R, et al., 2022 [123]
Retinol	Retinol, while known for its anti-aging properties, also offers benefits as an anti-pigmentation agent. By increasing cell turnover and promoting collagen production, retinol can help reduce hyperpigmentation, improve skin tone, and diminish the appearance of age spots.	Quan, T. 2023 [124]
Hydroquinone	Hydroquinone is an effective topical treatment for hyperpigmentation by inhibiting melanin production. However, its potential side effects necessitate professional prescription and monitoring. Despite regulatory restrictions in some regions, hydroquinone remains a relevant option for treating hyperpigmentation under appropriate guidance.	Fabian IM, et al., 2023 [125]
Azelaic Acid	Azelaic acid may be superior to hydroquinone in reducing melasma severity, according to a meta-analysis of randomized controlled trials. While both treatments showed similar safety profiles, azelaic acid demonstrated a greater reduction in MASI scores. This positions azelaic acid as a promising alternative for treating melasma.	Albzea W, et al., 2023 [126]
Hyaluronic Acid	A hyaluronic acid complex demonstrated depigmenting and anti-aging effects on human skin explants, reducing melanin content and reversing UV-induced damage. While the mechanism of depigmentation may be indirect, hyaluronic acid contributes to overall skin health, which can improve skin tone and reduce the appearance of hyperpigmentation.	Siquier-Dameto G, et al., 2023 [127]
ProceradTM	Procerad™, a patented ceramide within a multi-targeted dermocosmetic cream, contributes to reducing acne-related blemishes, likely by supporting skin barrier restoration and reducing inflammation, thus helping prevent post-inflammatory hyperpigmentation. This, combined with other beneficial ingredients like niacinamide and Aqua Posae Filiformis, makes the cream a promising option for managing acne and preventing post-acne marks.	Dal Belo SE, et al., 2024 [97]
MelasylTM	Melasyl™ (2-MNG) effectively prevented both immediate and delayed UV-induced skin darkening in a clinical study. Its potent anti-pigmentation effects were further enhanced when combined with exfoliating and sunscreen ingredients, highlighting its promise as a multifaceted approach to preventing hyperpigmentation.	de Dormael R, et al., 2024 [128]
Salicylic Acid (SA)		Ravikumar, et al., 2021 [129]

details the scientific evidence supporting their efficacy. Notably, some ingredients have more than one mode of operation on the skin (e.g., concurrent anti-inflammatory, keratolytic, and anti-pigmentation effects) [30]. Figure 3 introduces acne dermocosmetics that can be applied according to the patient’s skin type (sensitive, oily, dry) and acne severity (mild, moderate, severe, post-acne status).

3.3. Acne Treatment and Management

3.3.1. Preadolescent Acne

i.

Characteristics of preadolescent acne

Acne vulgaris, a prevalent skin condition, affects individuals of all ages, including children as young as 7–11 years old [31,32]. This shift towards an earlier onset, termed preadolescent acne (presenting in children aged 7–11 without underlying endocrinological disorders), is concerning as it is linked with greater severity and a heightened risk of scarring later in life [31,32,33,34,35]. While acne peaks during puberty due to hormonal changes, it can persist for years and even into adulthood [36,37].

Treating preadolescent acne presents unique challenges. Most treatment guidelines and research focus on patients aged 12 and older, leading to limited evidence for this younger population [38]. Additionally, concerns arise regarding potential systemic effects, impact on growth and development, the psychosocial influence of acne, and treatment adherence [38].

ii.

Pathogenic pathways/epidemiology

A 5-year cohort study of young girls identified that early development of significant comedones was associated with more severe acne in later years [39]. Furthermore, a prospective study involving children aged 5–12 years showed that excess sebum and Cutibacterium acnes (formerly Propionibacterium acnes) colonization were seen earlier in both prepubertal and pubertal children who subsequently developed acne compared to those who did not [40]. This suggests that the biological processes underlying acne development are already in motion years before the typical onset of puberty.

Clinically, preadolescent acne often presents as comedones predominantly located on the forehead, central face (T-zone), and ears, with fewer inflammatory lesions [31]. This early comedonal presentation underscores the importance of recognizing and addressing acne in its early stages, as it may indicate more severe acne in adolescence and adulthood.

iii.

Optimizing acne treatment with dermocosmetics for preadolescent acne

Before initiating any acne-specific therapies, it is important to check skin sensitivity. For patients exhibiting sensitive skin, a foundational approach focusing on strengthening and restoring the skin barrier using specifically targeted dermocosmetics is recommended. The panel emphasized the importance of a gentle approach in this age group due to the potential for irritation and the psychological impact of aggressive treatments. Once skin sensitivity is addressed, acne treatment can be initiated, starting with an acne cleanser. For mild cases primarily affecting the T-zone, topical medications and dermocosmetics are typically the first-line treatments. Topical retinoids, BPO, or fixed combinations are effective due to their action on microcomedones and their broad-spectrum antimicrobial properties [41,42]. However, in preadolescents with milder forms of acne, dermocosmetics can be prioritized over medications, while more severe cases may necessitate topical medications, potentially combined with dermocosmetics.

When acne affects the entire face or presents a risk of scarring or pigmentary changes, a broader approach incorporating physical modalities, such as extraction, chemical peels, and laser therapies, may be warranted. The panel recommended that these modalities can also be considered in cases of mild acne with significant sebum production. Following these procedures, it is crucial to prioritize skin barrier repair, microbiome balance, photoprotection, and anti-pigmentation strategies using appropriate dermocosmetics. Treatment adherence can be challenging in preadolescents due to parental concerns about oral medications and potential side effects. This highlights the crucial role of dermocosmetics, which can mitigate these concerns, improve adherence, and serve as valuable adjunctive or primary therapy, especially when pharmaceutical interventions are not preferred. The panel emphasized that educating both parents and patients about the benefits and importance of dermocosmetics is paramount for optimizing acne management in this age group.

iv.

Consensus-based algorithm for preadolescent acne

The preadolescent acne treatment algorithm is summarized in Figure 4.

3.3.2. Adolescent (From 12 Years) and Adult Acne

i.

Characteristics of adolescent and adult acne

Adolescence, typically defined as the stretch between 12 and 19 years of age, is often marked by the onset of acne. During this period, acne manifests with various characteristics such as comedones, papules, pustules, and nodules.

Acne persists into adulthood for many individuals, particularly women, either continuing from adolescence or having an onset in adulthood [43]. This prevalence in women is often linked to hormonal factors, particularly hyperandrogenism, which can be exacerbated by conditions such as polycystic ovary syndrome (PCOS).

PCOS is a hormonal disorder that affects women of childbearing age, characterized by irregular periods, elevated androgen levels, and the development of small cysts in the ovaries. PCOS is a significant contributing factor to adult female acne, with studies indicating a higher prevalence of PCOS (51%) among patients with severe acne [44,45].

ii.

Pathogenic pathways/epidemiology

Acne vulgaris, whether in adolescence or adulthood, hinges on a common pathogenic pathway: the interplay between sebum production, inflammation, and C. acnes proliferation. While typically emerging between 12 and 19 years of age, acne often persists or has an onset in adulthood, disproportionately impacting women [43,46]. This gender disparity is largely attributed to the influence of hyperandrogenism, often exacerbated by conditions like PCOS, which affects a significant portion of women with severe acne [44].

Elevated androgens, whether during puberty or due to conditions like PCOS, stimulate sebaceous glands, leading to increased sebum production—a key driver of acne [45]. However, hyperandrogenism not only elevates sebum quantity but also critically alters its composition, increasing pro-inflammatory lipids and compromising the skin’s barrier function [44]. This creates a milieu primed for inflammation and the proliferation of C. acnes. Virulent C. acnes strains, thriving in this altered sebum environment, break down triglycerides, releasing free fatty acids that further assist bacterial colonization, amplify inflammation, and contribute to acne lesions, potentially culminating in scarring.

iii.

Optimizing acne treatment with dermocosmetics for adolescent and adult acne

Adult acne often presents similarly to adolescent acne, except for cases of severe scarring or deep cystic lesions concentrated in areas like the jawline, which may necessitate procedures like laser therapy [46]. This observation raises the question of whether a distinct separation of treatment strategies for adolescents and adults is necessary, prompting a unified approach in these guidelines.

The panel unanimously agreed that for adolescents and adults with acne, particularly those experiencing increased sebum production, treatment typically begins with the recommendation of an acne-specific cleanser.

Acne treatment is tailored to its severity. For mild cases, managing sebum, gentle exfoliation, and maintaining a healthy skin barrier are key. While topical treatments like BPO and retinoids are commonly used, dermocosmetics focusing on physical and microbial barrier support can be considered, particularly if conventional treatments cause dryness [5,47,48]. Moderate to severe acne often requires oral antibiotics (for a limited duration due to resistance concerns) alongside dermocosmetics to address multiple pathogenic factors [49]. If these prove inadequate, oral isotretinoin may be necessary, often supplemented with dermocosmetics to manage side effects [28,49].

Managing hyperandrogenism is crucial in adult female acne, especially in the context of PCOS, where mild acne is uncommon [44]. The panel recommended dermatologists to play a vital role in recognizing hyperandrogenism and initiating treatment, often consulting with pediatric endocrinologists for adolescents or referring to gynecologists for adult patients. Hormonal therapy is central to managing hyperandrogenism, with combined oral contraceptives (COCs) serving as the first-line treatment. For persistent or severe acne despite COCs, spironolactone, an anti-androgen, is often added. Alongside hormonal interventions, topical drugs such as retinoids, benzoyl peroxide, or fixed-dose combinations are typically incorporated. Antibiotics may also be considered as needed, while isotretinoin is reserved for cases with unsatisfactory responses to other treatments, often used in conjunction with COCs [44,49].

iv.

Consensus-based algorithm for adolescent and adult acne

The adolescent and adult acne treatment algorithm is summarized in Figure 5.

3.3.3. Acne in Atopic Dermatitis

i.

Characteristics of acne in atopic dermatitis

Atopic dermatitis (AD) and acne often coexist in adolescents, particularly after the age of ten, due to potential overlap in affected areas [50]. A Danish study reported an increased risk of acne in AD individuals over 30 years of age, but with no increased risk for overall acne from their cohort (n = 6600) [51]. Another self-reported study (n = 482) also found no connection between acne and AD [52]. In acne patients with AD, the inflammatory nature of both conditions can create a vicious cycle, with excoriation of acne lesions further disrupting the skin barrier and exacerbating AD [53]. Therefore, control of both conditions is crucial.

ii.

Pathogenic pathways/epidemiology

AD is characterized by both skin microbial dysbiosis and barrier dysfunction. Initially, inflammation in AD exhibits a Th2 profile in response to allergens, which is later amplified by the disruption of the skin barrier and a reduction in antimicrobial peptides. This environment promotes the growth of skin pathogens, primarily Staphylococcus aureus, and leads to a shift in the immune response towards a Th2, Th1, and Th17 pattern. On the other hand, acne is associated with changes in the skin microbiome, hormonal imbalances, and excess sebum production, resulting in a cutaneous inflammatory process mediated by Th1 and Th17 cells. This inflammatory response also involves the activation of Toll-like receptors by antigens from C. acnes [53].

Unlike others, a Finnish study found a significantly higher risk of acne in AD patients than in controls [54]. Interestingly, the risk of acne increased with AD severity, which is likely because this population used more comedogenic topical treatments and oral steroids than that with milder AD [54].

iii.

Optimizing acne treatment with dermocosmetics in AD

Managing acne in patients with AD requires a balanced approach addressing both conditions without increasing skin sensitivity. The panel reiterated the crucial role of skin barrier repair as the foundation of acne treatment in AD patients, suggesting that a compromised barrier can exacerbate both conditions. Dermatologists should prioritize in restoring and maintaining a healthy skin barrier, as AD itself can predispose individuals to acne.

For all individuals with AD and acne, dermocosmetics formulated for sensitive skin are recommended as the first-line approach [8]. These should focus on strengthening the skin barrier, rebalancing the skin microbiome, and providing gentle cleansing. Conventional acne medications should be introduced cautiously, especially topical BPO or retinoids, as these can easily irritate the skin.

In mild acne, dermocosmetics targeting sebum control and gentle exfoliation are preferred [8]. Moderate to severe acne may warrant a combination of oral antibiotics and dermocosmetics with sebum-regulating, keratolytic, and anti-inflammatory properties. The panel recommended short courses of oral antibiotics in conjunction with anti-inflammatory and barrier-repairing dermocosmetics, prioritizing long-term management with dermocosmetics and topical treatments to maintain remission and prevent flares of both AD and acne.

Importantly, oral isotretinoin, while effective for acne, is generally not recommended in this population due to its potential to worsen skin dryness. The panel strongly discouraged the use of oral isotretinoin in AD patients due to the high risk of exacerbating dryness and skin barrier dysfunction. Furthermore, as individuals with AD are prone to persistent erythema and acne scarring, strict photoprotection and dermocosmetics with anti-pigmentation ingredients are crucial.

iv.

Consensus-based algorithm for acne in atopic dermatitis

The adolescent and adult acne treatment algorithm in patients with AD is summarized in Figure 6.

3.3.4. Acne in Pregnancy

i.

Characteristics of acne in pregnancy

Acne poses a common challenge for pregnant and lactating women. However, clinical management of acne in these individuals is often suboptimal due to the scarcity of safety data and consistent guidelines regarding the use of anti-acne therapies [55]. This presents a significant concern, as acne can be particularly bothersome for women who are planning pregnancy or already pregnant, given the physiological changes and unpredictable nature of acne during this period [56].

Managing acne in pregnant women can be especially challenging due to the limited therapeutic options at hand. Clinical trials involving pregnant populations are ethically constrained, resulting in a lack of published studies on acne treatment specifically for this group. As a result, healthcare providers must navigate treatment decisions cautiously, minimizing risks of both the mother and the developing fetus [57].

ii.

Pathogenic pathways/epidemiology

While the precise mechanisms driving acne during pregnancy are not fully elucidated, hormonal fluctuations and immunological changes appear to play significant roles [55,57,58]. Although pregnancy typically involves increased estrogen and progesterone levels, which theoretically should improve acne with the suppressed testosterone level, increased sebaceous gland activity, particularly in the third trimester, is frequently observed [58].

Pregnancy-related immunological shifts may also allow the development of inflammatory acne, which tends to be more prevalent and widespread, often involving the trunk [57,58]. Women who have had acne in the past appear to be at increased risk during pregnancy [57].

Both pregnant and breastfeeding individuals have great concerns about the potential scars from acne inflammation.

iii.

Optimizing acne treatment with dermocosmetics in pregnancy

Managing acne in pregnant and lactating women is a unique challenge for dermatologists with worries of maternal and fetal safety [55,59,60]. The panel emphasized shared decision-making with pregnant and lactating patients, carefully weighing the risks and benefits of any treatment. Treatment decisions must carefully weigh the severity of acne, potential medication risks, and the patient’s willingness to tolerate these risks [55,59,60]. Given the limitations on drug use during pregnancy and lactation, dermocosmetics emerge as a crucial component of acne management in this patient population.

Pregnant women often experience excess sebum and a higher incidence of inflammatory acne, making sebum control and anti-inflammatory support through dermocosmetics paramount [55,58]. While topical treatments like benzoyl peroxide and azelaic acid are generally preferred, dermocosmetics are crucial for mitigating potential adverse reactions and promoting keratinization [55,59]. Prioritizing dermocosmetics as the primary treatment modality, even in mild cases, can potentially delay or prevent the need for medications as acne severity progresses [55,59]. This approach prioritizes maternal and fetal safety while addressing the patient’s dermatological needs. The panel advised that the goal of acne management during pregnancy and lactation is often to control rather than completely clear acne, prioritizing the safest and most tolerable approaches. Furthermore, in cases of comedonal acne, physical modalities like comedone extraction can be considered in conjunction with appropriate dermocosmetics, allowing for a comprehensive approach that minimizes medication use.

Selecting dermocosmetics for pregnant and lactating patients requires meticulous attention to ingredient safety. Clinicians should carefully review product formulations to ensure they are free of potentially harmful ingredients, prioritizing those specifically designed for sensitive skin and formulated for use during pregnancy.

iv.

Consensus-based algorithm for acne in pregnancy and lactation

The acne management algorithm during pregnancy and lactation is summarized in Figure 7.

3.3.5. Drug-Induced Acne

i.

Characteristics of drug-induced acne

Drug-induced acne presents with classic acne symptoms but is distinguished by its sudden onset, atypical age of onset (often outside the typical age range of acne), and distribution patterns [61]. Clinically, drug-induced acne often manifests as a sudden eruption of itchy, follicular-based inflammatory papules and pustules, sometimes with punctiform vesicles [62].

Several medications can induce this type of acne, with corticosteroids being a common culprit, often causing steroid acne within two weeks of starting systemic or topical treatment [61]. While more frequent in adults, steroid acne can be seen in children and infants. JAK inhibitors, increasingly used in dermatology, are also associated with an increased incidence of acne, particularly with higher dosages [63,64].

Beyond corticosteroids and JAK inhibitors, a wide range of medications can cause drug-induced acne, including lithium, vitamin B12, thyroid hormones, halogen compounds, certain antibiotics (e.g., macrolides), antituberculosis drugs, and epidermal growth factor receptor inhibitors [61]. This highlights the importance of a comprehensive medication history when evaluating patients with suspected drug-induced acne.

ii.

Pathogenic pathways/epidemiology

While the precise mechanism of steroid acne remains elusive, expedition of infundibular spongiosis, hyperkeratosis, microcomedo formation, and hair follicle rupture appears to be central to the eruption of papules and papulopustules. Several studies suggest that steroid-induced TLR2 activation, in conjunction with C. acnes, plays a key role in exacerbating acne vulgaris [61].

In the case of JAK inhibitor-induced acne, JAK inhibitors may induce follicular hyperkeratinization by modulating epidermal growth factor receptors. Additionally, blockage of JAK1 receptors prompts Th1 immune deviation, resulting in changes in the skin’s microbial colonization [64].

Another significant contributor to drug-induced acne is the prolonged use of oral antibiotics, particularly macrolides, for acne treatment. This extended use contributes to an increase in macrolide-resistant C. acnes strains. After discontinuing antibiotic treatment, these tolerant C. acnes strains may persist on the skin for an extended time, often leading to a recurrence of acne. Furthermore, when re-treatment with antibiotics becomes necessary, the efficacy of these drugs is often diminished due to the presence of resistant strains [65].

iii.

Optimizing acne treatment with dermocosmetics for drug-induced acne

When managing drug-induced acne, it is crucial to first identify the causative medication and carefully assess the patient’s skin condition before initiating any treatment. For instance, in cases of steroid acne, abruptly discontinuing corticosteroid therapy due to acne development can often worsen the condition. Therefore, it is generally advisable to maintain the existing medication regimen while addressing acne as a separate issue.

For mild steroid acne arising during treatment, adjunctive therapy with dermocosmetics is often a suitable initial approach. These ingredients can help soothe irritation and reduce inflammation. However, if moderate to severe acne develops, a mixture of topical agents, oral antibiotics, and dermocosmetics targeting key pathogenic factors such as sebum control, keratolytic action, and anti-inflammatory properties is recommended. Furthermore, as long-term corticosteroid use can compromise skin barrier integrity, incorporating dermocosmetics that support skin barrier function both during and after treatment is crucial. The panel recommended continuing barrier-repairing dermocosmetics even after discontinuation of corticosteroids to promote long-term skin health and prevent recurrences.

JAK inhibitors, increasingly utilized in dermatology, can also trigger acne by stimulating hyperkeratinization of hair follicles and disrupting the skin microbiome [63,64]. While oral medications might be considered for patients experiencing significant distress or worsening acne due to JAK inhibitors, many cases can be effectively managed with topical agents or dermocosmetics [64]. Therefore, exploring these less aggressive options is initially recommended. The panel suggested starting with dermocosmetics for JAK inhibitor-induced acne (JAKNE) and escalating, acknowledging the potential for topical therapies to cause dryness or irritation, especially in individuals with AD.

Adapalene/BPO, a common topical treatment for JAK inhibitor-induced acne (JAKNE), can sometimes lead to dryness or irritation, especially in individuals with AD. In these cases, utilizing dermocosmetics that regulate keratinization and support a healthy microbiome can be of great benefit.

iv.

Consensus-based algorithm for drug-induced acne

The drug-induced acne treatment algorithm is summarized in Figure 8.

3.3.6. Acne Cosmetica

i.

Characteristics of acne cosmetica

Acne cosmetica, first described in 1972 by Kligman and Mills, refers to acneiform lesions specifically triggered by using cosmetics [66,67]. It typically presents as persistent, low-grade closed comedones that resolve slowly upon discontinuation of the causative cosmetic product [66,67].

While increased awareness of non-comedogenic testing and readily available information on comedogenic ingredients have significantly reduced the incidence of acne cosmetica, certain substances, particularly oils and greases applied to the scalp and face, can still induce comedonal lesions [68]. However, it is important to note that the existence of a comedogenic ingredient in cosmetic goods does not mean that the product is comedogenic. The concentration of the ingredient plays a crucial role, with even highly comedogenic ingredients potentially having minimal impact at lower concentrations [69].

Diagnosing acne cosmetica relies heavily on a thorough history, and it is crucial to ask the patient’s cosmetic use and the onset of acne [66]. It typically affects women aged 20–40 years and presents as persistent closed comedones, with minimal inflammatory lesions or scarring [66]. Pomade acne, a variant of acne cosmetica, is characterized by closed comedones limited to areas where pomade is applied [70].

Differentiating acne cosmetica from acne vulgaris, particularly post-adolescent acne, is essential as adult female acne is more common than previously thought [71]. This distinction guides appropriate management, focusing on identifying and eliminating the causative cosmetic product in cases of acne cosmetica.

ii.

Pathogenic pathway/epidemiology

When something is comedogenic, it triggers acne by obstructing the pores and hair follicles. Comedogenic products, combined with excess sebum and keratinocytic debris, accumulate within the hair follicles, blocking the pores and leading to acne. Common risk factors for developing acne cosmetica include heavy creams, oils, pomades, and makeup. The intricate interaction between sebum and trapped comedogenic makeup contributes to the onset of acne cosmetica. This condition is characterized by persistent mild breakouts, primarily consisting of comedones on the forehead, cheeks, neck, and scalp. Papules and pustules may occasionally accompany acne cosmetica, although they are less common [72]. Often, a detrimental cycle ensues as acne worsens, with more cosmetics applied to conceal the lesions, perpetuating the problem.

Not only skincare products but also men’s makeup items like blemish balm and concealer have become popular among males, even at a young age. This suggests that we should consider the potential impact of cosmetics on acne regardless of a person’s gender [23].

iii.

Optimizing acne treatment with dermocosmetics for acne cosmetica

Managing acne cosmetica generally mirrors acne treatment, with the critical first step of identifying and discontinuing the causative cosmetic product for at least six months [72]. The panel stressed the importance of a detailed cosmetic history, including all products used on the face, scalp, and hair, to identify potential comedogenic culprits. Simplifying cosmetic routines and being selective with the cosmetic ingredients are crucial, especially for heavy cosmetic users.

Following discontinuation of the product, adjunctive dermocosmetics can be beneficial, particularly for mild cases. Dermocosmetics that regulate sebum production, enhance exfoliation, soothe, and hydrate can support skin health and recovery. The panel recommended that acne cosmetica prevention involves using oil-free or non-comedogenic products [71], removing makeup with oil-free or water-based cleansers, and prioritizing photoprotection.

Incorporating dermocosmetics that strengthen the skin barrier is particularly important given the potential of topical benzoyl peroxide and retinoids to cause dryness and irritation [29]. Additionally, topical anti-pigmentation agents can address post-inflammatory hyperpigmentation (PIH), a regular concern in acne cosmetica.

Korea’s high accessibility to healthcare translates into frequent patient/doctor interactions, presenting a unique advantage in managing skin health. This easy access to dermatological care likely contributes to the lower incidence of acne scarring and generally good skin health observed in the Korean population. Patients are more likely to seek professional guidance on skincare routines and product choices, allowing for early interventions and proactive management of skin conditions like acne cosmetica. Therefore, leveraging this accessibility for patient education on proper skincare practices, including product selection and thorough makeup removal, can further enhance preventive measures against acne cosmetica in Korea.

iv.

Consensus-based algorithm for acne cosmetica

The acne cosmetica treatment algorithm is presented in Figure 9.

4. Conclusions

Acne vulgaris presents a significant global health burden, demanding tailored treatment approaches. This is particularly critical in Asia, where the dermocosmetics market is rapidly expanding, yet standardized guidelines integrating these products for specific patient subgroups are lacking. Therefore, a panel of expert dermatologists specializing in acne management convened to develop a novel guideline, aimed at the efficacy and safety of dermocosmetics, particularly in conjunction with conventional treatments.

The resultant guideline is tailored to the following distinct patient subgroups: adolescent acne, adult acne, acne with comorbid AD, acne in pregnancy, drug-induced acne, and acne cosmetica. Across all subgroups, skin barrier and microbiome maintenance, photoprotection and anti-pigmentation measures should be taken. In adolescent and adult acne, sebum control, keratolytic and anti-inflammatory agents, and an acne cleanser are called for; in atopics, the skin barrier and microbiome should be protected foremost, with use of a gentle cleanser; and in pregnant and lactating women, use of acne dermocosmetics should be maximized due to limited treatment modalities. Effective active ingredients include salicylic acid (keratolytic, anti-inflammatory, and anti-pigmentation), niacinamide (sebum control, anti-inflammatory, barrier-enhancing, and anti-pigmentation), alpha-hydroxy acids, retinoid derivatives, zinc, panthenol, ceramide, and thermal water. Since dermocosmetics not only give synergistic effects with drugs but can also help minimize treatment side effects, prevent recurrence, and maintain remission, they should be incorporated into acne management to optimize outcomes and enhance patient adherence. The panel agreed upon advocating the use of dermocosmetics to provide more personalized, holistic, and effective care to individual acne patients in different subgroups. Provision of clear, practical guidelines on utilizing dermocosmetics alongside conventional therapies empowers both clinicians and patients to make informed decisions, optimize treatment outcomes, and improve adherence to long-term acne management strategies.