Rethinking Acne: The Skin Barrier Perspective

Original Article: Skin Barrier Dysfunction in Acne Vulgaris: Pathogenesis and Therapeutic Approaches

What are the key takeaways of this article?

Acne vulgaris is one of the most common dermatologic conditions worldwide and its pathogenesis is traditionally described by four main processes: increased sebum production, follicular hyperkeratinization, bacterial colonization and proliferation within obstructed follicles, particularly by Cutibacterium acnes, and subsequent immune mediated inflammation. However, Deng et al. highlight another important pathogenic factor that may be overlooked: damage to the epidermal skin barrier.

The skin barrier is the outermost protective layer of the epidermis, responsible for retaining moisture, preventing entry of irritants and microbes, and supporting a healthy skin microbiome. Individuals with acne often have weakened barrier function, resulting in increased transepidermal water loss, alterations in skin pH, increased erythema, and reduced microbial diversity. The extent of such changes often correlates with acne severity.

Overactive sebaceous glands can alter the composition of sebum, triggering localised auto-inflammatory responses. The release of pro-inflammatory cytokines such as interleukin-1 (IL-1), interleukin-6 (IL-6), and tumor necrosis factor-alpha (TNF-α) can disrupt intercellular junctions between keratinocytes, further weakening the skin barrier. Although Cutibacterium acnes normally acts as a commensal organism that supports the skin barrier by promoting keratinocyte differentiation, enhancing ceramide production, and maintaining tight junction structure, excessive proliferation or dysbiosis can shift these interactions toward pro-inflammatory signaling and barrier disruption. These intrinsic factors are further influenced by external environmental exposures,  collectively termed the “acne exposome”, including ultraviolet radiation, air pollution, harsh skincare products, dietary factors, and psychosocial stress, all of which can exacerbate barrier damage and precipitate acne flares.

Importantly, many standard acne treatments such as benzoyl peroxide, retinoids, and chemical peels can be irritating and worsen sensitivity if the skin barrier is already compromised.

Deng et al. emphasize that repairing and protecting the skin barrier is a key part of acne management. Evidence-based strategies include the use of gentle, non-alkaline cleansers; incorporation of barrier-supporting ingredients such as ceramides and certain plant extracts, including paeoniflorin and madecassoside; restoration of microbiome balance through probiotics; and adjunctive treatments such as low-level laser therapy. Emerging approaches such as mesotherapy may offer deeper barrier repair by using microneedles to induce controlled mico-injuries that stimulate skin repair pathways, although further research is needed to establish their efficacy and safety. 

Overall, this review encourages a more holistic, barrier-centred approach to acne, one that not only targets treating the altered skin microbiome and resulting inflammation, but also prioritizes epidermal skin barrier health to improve treatment outcomes and reduce acne recurrence.

Publication Date: January 29, 2026

Reference: Deng Y, Wang F, He L. Skin Barrier Dysfunction in Acne Vulgaris: Pathogenesis and Therapeutic Approaches. Med Sci Monit. 2024;30:e945336. Published 2024 Dec 13. doi:10.12659/MSM.945336

Summary By: Ella Liu