CLEANSERS AND THEIR ROLE IN VARIOUS DERMATOLOGICAL DISORDERS (2025)

Why we need cleansers?

Many of the environmental impurities and cosmetic products are not water soluble and so washing the skin with simple water would not be sufficient to remove them. Substances capable of emulsifying them into finer particles are to be used for making these fat soluble impurities water soluble. Herein, cleansers fit into the picture. Skin cleansers are surface—active substances (i.e. emulsifiers/detergents/surfactants/soaps) that lower the surface tension on the skin and remove dirt, sebum, oil from cosmetic products, microorganisms, and exfoliated corneum cells in an emulsified form. An ideal cleanser should do all these without damaging or irritating the skin, on the contrary it should try to keep the skin surface moist.[4]

Evolution of modern day cleansers

Cleansers can be divided into three basic types:

Cleanser variants

Adverse effects of soaps

Harsh cleansers such as soaps are known to cause:

1. After wash tightness it is a sensation of tightness perceived 5–10 min after washing with a soap. Rapid evaporation of water from the skin surface causes this tightness.[7]

2. Skin dryness, scaling and roughness-lipid solvents such as acetone, alcohols and even nonionic surfactants can cause dryness of the skin.[7] Cold weather and low humidity can aggravate these effects.

3. Skin irritation–skin irritation along with erythema and itching following the use of harsh soaps are mainly due to damage to the skin barrier.[7]

4. Allergic contact dermatitis to the fragrances, preservatives, or dyes present in some soaps.

Factors causing dryness and irritation in cleansers

The major factors affecting the drying and irritancy potential of cleansers, include type and rinsability of surfactant ingredients and to a lesser degree pH.[3]

1. Surfactant ingredients: Surfactants after binding to keratin cause protein denaturation, thus leading to damage to the cell membrane of keratinocytes. This in turn leads to adverse cutaneous responses.[5] Surfactant chain length is also an important factor in determining the irritant potential with Kellum opining that the most noticeable irritant reactions developed with fatty acids having chain lengths from C8 to C12 coming in contact with the skin.[1] Although anionic surfactants are considered to have the greatest irritancy potential, their proportion in a cleansing agent and their combination with cationic acrylate polymers or nonionic surfactants and humectants like propylene glycol modifies the irritation potential.

2. Skin cleanser residue or rinsability factor: The irritancy potential of a cleansing agent may increase the longer it is left on the skin. Residual levels of different products on the skin vary, and these levels correlate with irritation reactions.[5]

3. pH of cleansing agent: Although controversial, but still many dermatologist believe that maintaining the skin surface at its physiological pH (4–6.5) during cleansing prevents overgrowth of certain microorganisms, like Propionibacterium acnes. Soaps with an alkaline pH have also been said to cause damage to the lipid bilayer of the stratum corneum thus causing dryness of the skin.[5] However, other workers have shown that the pH of a cleanser appears to have little effect on its role in damaging the skin.[1] Present day synthetic detergents and lipid free cleansers have a neutral or slightly acidic pH which closely matches the skin pH.

Considering all these factors, it can be concluded that synthetic detergents and lipid free cleansers have the least irritancy potential compared to other market products. A recent study has compared the 31 cleansers available in the Indian market and has proven the above.[8]

Use of cleansers in various dermalogic disorders

For normal skin choosing a particular cleanser is less important as compared to people with dermatological disorders such as atopic dermatitis, acne vulgaris, rosacea, photoaging, occupational dermatosis, perianal pruritus, and sensitive skin. In all these cases, a cleansing agent that can be used along with topical therapies and also is biocompatible with the skin condition should be recommended [Table 2].[5]

Cleansing in atopic dermatitis

Atopic dermatitis (AD) develops as a result of a complex interrelationship of environmental, immunologic, genetic, and pharmacologic factors.[9] Several trigger factors such as irritants (soap and detergents, occupational irritants, and disinfectants), microorganisms (Staphylococcus aureus, viruses, and dermatophytes), aeroallergens, seasonal changes, and psychogenic factors may aggravate the disease. Although most dermatologists agree that the skin of patients of atopic dermatitis should be kept clean, there is no unanimity of opinions regarding the use of common toilet soaps for cleansing the skin in the course of management of this condition. Washing twice daily with a classic alkaline soap (pH 10.2) has shown to reduce the stratum corneum cell layer and caused attrition of intercellular lipids in individuals suffering from atopic dermatitis. This damage to the skin barrier function could result in increased colonization of gram-positive bacteria.[5]

Since soaps have an irritant effect on skin and AD patients typically demonstrate a diminished irritant threshold, therefore, synthetic washing bars are a good choice for cleansing in these patients. Their mildness and ability to maintain proper hydration of the stratum corneum are a boon for the atopic dry skin.[10]

Cleansing in acne

The goal of cleansing for acne or acne-prone skin is to gently remove surface dirt, sweat, and excessive skin lipids without irritating or drying the skin. The ideal cleanser for acne skin should be:

1. non comedogenic,

2. non acnegenic,

3. non irritating, and

4. non allergenic.[11]

The myth associated with acne that vigorous scrubbing of the skin with soap and water several times a day will reduce the oiliness; however, only leads to an aggravation of acne and sometimes even may cause acne detergicans.

There is a wide spectrum of skin cleansing agents for acne prone patients ranging from lipid free cleansers, syndets, astringents, exfoliants, and abrasives.[12] The major side effects of most antiacne therapies are dryness and irritation of the skin, so gentle cleansing is important in these group of patients. A nonionic, fragrance-free dermatologic bar or liquid cleanser with good rinsability is the preferred cleanser in acne. The cleansing regimen should suit the needs of the individual patient.[11]

Cleansing in photoaged skin

Excessive long-term exposure to sunlight damages the skin, and is known to cause premature aging and skin cancer. Since these persons have an already compromised skin surface, so lipid free cleansing agents containing humectants and emollients also can help in reducing the severity of some of the symptoms associated with photoaged skin.[5]

Cleansing in occupational dermatosis

Occupational dermatosis is an important group of disorders encountered in practice. Among them, contact dermatitis, both irritant and allergic are of special concern. Prevention is the key to reduce the incidence and prevalence of both forms of contact dermatitis. Avoidance of causative irritants both at home and the workplace is the primary treatment of contact dermatitis. People suffering from these disorders should practice good skin care daily. Skin cleansing products are equally important both as skin protection and skin care products in an industrial setup for removal of soiling. Skin compatible hand cleansing is vital for the prevention of occupational dermatitis.[14] The basic requirements for an efficient skin cleanser to prevent occupational skin diseases are its easy solubility in both hard and soft water, its ability to remove fats, oils, greasy materials without drying the skin, its free flow through the dispensers and a long shelf life without easy deterioration on storage.[15]

In reality, however no cleanser can be labeled as ideal for occupational dermatosis. While liquid synthetic detergents are generally perfectly adequate for cleansing hands at home, more powerful hand cleansers are needed for the removal of heavy duty industrial soiling such as oil, grease, paints, and lacquer. Products free from scrubbing agents are usually skin friendly and preferred by dermatologists.[14]

Cleansing in xerotic skin

Xerotic skin is seen in several dermatological disorders and also in the geriatric population as a part of natural aging due to decreased sebum production. Environmental factors, such as low humidity and wind may also exacerbate dryness. To rehydrate and soften xerotic skin, emollients, humectants, or keratin-softening agents should be applied liberally—immediately after bathing and reapplied as often as necessary to soften xerotic skin and rehydrate it.[16] People with xerosis should use cleansing agents that do not cause further dryness, and ideally contain humectants and/or emollient ingredients.

Cleansing in “sensitive skin”

Dermatologists and cosmetic scientists define “sensitive skin” as that which exhibits contact irritant or allergic reactions more readily than the average population.[17]

This increased reactivity to external factors can be due to:

1. physiologic phenomenon,

2. heightened neurosensory input,

3. increased immune responsiveness and/ or

4. compromised barrier function.[18]

Frosh recommends that people who have sensitive skin should use very mild cleansing agents.[5] Liquid facial cleansers are highly effective and beneficial for sensitive skin. These can also be used synergistically with topical or systemic therapy.[4]

Cleansing in retinoid-induced dermatitis and post-chemical peel cleansing-induced sensitive skin

Topical retinoids used in a wide variety of dermatological disorders increase skin susceptibility to irritation. In these cases, the patient should use a cleanser that does not aggravate the state of their weakened barrier. The humectants and emollients found in lipid-free cleansers could help lessen the symptoms of these disorders.

Facial chemical peelsare rapidly becoming popular as cosmetic procedures for treatment of photoaging, wrinkles, scars, and discoloration. Peeling produces controlled injury to the skin that promotes the growth of new skin with an improved appearance. Since the skin is vulnerable following the procedure and subsequent period of epithelial regeneration, mild cleansing agents are to be used to avoid adverse reactions.[10]

Cleansing in idiopathic perianal pruritus

Perianal pruritus is defined as an unpleasant cutaneous sensation that induces scratching of the skin around the anal orifice. It can be primary or idiopathic when no apparent cause can be found or secondary due to an identifiable etiology. Topical corticosteroids are quite effective in controlling idiopathic perianal pruritus, but long-term use can cause atrophy of the skin of the anogenital area. Perianal cleansing with mild liquid cleansers containing humectants can be a safe initial step for controlling perianal itching and can be as effective as topical corticosteroids.[19]