Acne Vulgaris on the Upper Back and Chest Induced by Moisturizer Overuse: A Brief Review of a Case

Abstract

Acne vulgaris is a common skin condition often causing physical and emotional distress. We reported a case of 27-year-old female with rash and acne over the chest and upper back following continuous application of moisturizer. This case emphasizes the role of comedogenic moisturizers in acne development or worsening by disrupting the skin’s natural barrier, especially on oily areas including the chest and upper back. We aim to highlight an underrecognized but significant factor in developing acne vulgaris resulting in psychosocial impact and morbidity.

1. Introduction

Acne vulgaris is a common irritating skin condition in adolescents and adults, comprising pimples, comedones, pustules, nodules, and cysts due to chronic inflammation of hair follicles and associated sebaceous glands. Hyperpigmentation, scarring, and other visual manifestations of acne often result in psychological complications such as depression and social morbidity, which can affect a person’s wellbeing [1]. Herein, we present a 27-year-old female patient who developed acne vulgaris spread diffusely over the upper back and chest area after excessive use of comedogenic moisturizer.

2. Case Synopsis

We report the case of a 27-year-old female presenting with rash and moderate erythematous maculopapular/pustular acne over the chest and upper back after applying a thick layer of moisturizer containing glycerin, dimethicone, and cetyl alcohol covering 20% body surface area (BSA) three times a day for three months with a sponge-tipped back lotion applicator (Figure 1). Multiple papules on the chin were also noted. The moisturizer was not applied to the chin area, and the mild lesions on the chin noted at initial presentation were mild and most likely part of the patient’s underlying acne tendency, which showed resolution alongside treatment. The initial presentation was consistent with moderate acne vulgaris, with the involvement of trunk regions and some facial lesions. The patient was initially treated with 100 mg/day of oral minocycline (1 mg/kg/day) and tretinoin 0.025% topical cream application per night on the affected areas as prescribed by a primary care physician (PCP). During a 4-week follow-up visit to PCP, the minocycline dosage was increased to 200 mg/day (2 mg/kg/day) due to new lesions. After 3 weeks of double dosing minocycline, the patient presented with hyperpigmentation and rare papules on the back and erythema and fresh papules on the left chest (Figure 2). On a dermatology referral follow-up a month later, the patient presented with inflammatory papules and pustules distributed on the trunk and post-inflammatory hyperpigmentation. Minocycline was discontinued. The treatment plan included 80–160 mg of oral Bactrim twice per day, Adapalene 0.3% topical gel daily, and sulfacetamide–sulfur (Avar) 10–5% topical cleanser daily. After six months of treatment, the chest and back acne was resolved, with widespread hyperpigmentation and improved acne on the back (Figure 3).

3. Case Discussion

This case highlights an underrecognized but clinically significant factor in the development of acne vulgaris: overuse of comedogenic moisturizers, particularly on areas prone to oiliness such as the upper back and chest. Relevant details on the patient’s intrinsic and extrinsic risk factors to her acne presentation and overall skin health include the following:

• Skin type: Fitzpatrick type IV;
• Menstrual and hormonal profile: Regular menses, with no clinical or biochemical signs of hormonal imbalance and no features suggestive of PCOS;
• Contraceptive history: Not using hormonal birth control;
• Psychosocial factors: The patient reported mild emotional impact due to the visibility of acne lesions and post-inflammatory pigmentation;
• Smoking/alcohol use: Non-smoker and infrequent alcohol consumption;
• Environmental factors: No notable occupational or environmental exposures;
• Family history: Positive for acne in first-degree relatives.

This patient’s presentation underscores the importance of recognizing the role of exogenous contributors, including topical products, in the pathogenesis of acne. This discussion integrates findings from the existing literature to contextualize this case and the management and prevention of acne vulgaris.

Acne vulgaris is a multifactorial condition involving genetic predisposition, hormonal fluctuations, sebaceous gland activity, microbial colonization, and immune responses. Overuse of occlusive or comedogenic moisturizers can exacerbate these underlying mechanisms.

Comedogenic moisturizers with a high lipid content, for instance, may contribute to acne pathogenesis through several mechanisms and alter the skin’s microenvironment, including promoting hyperkeratinization, causing an abnormal increase in keratinocyte proliferation that leads to follicular plugging, and delaying natural desquamation of epidermal cells, resulting in comedone formation and follicular occlusion and supporting the growth of Cutibacterium acnes (formerly Propionibacterium acnes), a key pathogen implicated in acne pathogenesis. Additionally, excessive product application may promote an anaerobic environment conducive to bacterial proliferation and subsequent inflammatory cascades [2,3,4].

Moisturizers often contain comedogenic ingredients like occlusive agents and emollients, such as isopropyl myristate, lanolin, mineral oil, and certain fatty alcohols including cetyl and stearyl alcohol, which have been associated with acne development in individuals with acne-prone skin. Although these ingredients are generally safe for people with dry or sensitive skin, they can contribute to pore blockage and exacerbate acne symptoms in predisposed individuals. Historically, the tendency of topical products to cause comedones has been evaluated using in vivo tests such as the rabbit ear model, though the accuracy of this method for predicting human skin responses is debated. More relevant approaches involve testing on acne-prone individuals with patch tests or counting comedones, but these lack standardized procedures. Current research emphasizes the importance of assessing full product formulations instead of single ingredients [5].

Patients excessively using comedogenic moisturizers may observe early warning signs such as the appearance of new comedones (blackheads and whiteheads), a greasy or sticky skin texture, clogged pores, and the sudden onset or worsening of inflammatory papules or pustules. These changes typically occur in areas of application and may serve as clinical cues to discontinue or modify product use.

Emerging insights in recent research underscore the importance of maintaining a balanced cutaneous microbiome and intact SC barrier in acne prevention and management. Marson et al. (2022) emphasize the interplay between microbiome dysbiosis and SC dysfunction in acne pathogenesis, recommending skincare regimens that support microbial balance and barrier repair [6]. Similarly, Schachner et al. (2023) highlight the role of ceramide-containing moisturizer in restoring barrier integrity, particularly in individuals prone to acne and other inflammatory dermatoses [7].

In this case, the patient’s excessive use of comedogenic moisturizers likely disrupted the stratum corneum’s (SC) barrier function. Research indicates that impaired SC barrier function combined with altered sebum composition can lead to microcomedone formation, a precursor to inflammatory lesions [8,9,10]. Excessive moisture on already oily skin may augment sebum production and exacerbate follicular hyperkeratinization, creating an ideal environment for acne development [11].

The treatment of acne vulgaris necessitates a multifaceted approach, as exemplified in this case. This case underwent a transition from systemic antibiotics with limited efficacy to a regimen incorporating oral Bactrim and topical agents including adapalene, sulfacetamide, and sulfur cleanser to align with evidence-based recommendations for managing moderate to severe acne. Adapalene, a third-generation retinoid, is particularly effective in reducing keratinocyte proliferation and promoting desquamation, thus addressing both comedone formation and inflammatory lesions [12]. Sulfacetamide–sulfur cleansers complement this action by reducing microbial load and mitigating inflammation, offering a synergistic effect when combined with retinoids [13].

Post-inflammatory hyperpigmentation (PIH) presents another challenge, particularly in individuals with Fitzpatrick skin types III to VI; early intervention is crucial in minimizing PIH severity and chronicity. Considering that pigmentation changes can persist for months following acne resolution, topical retinoids not only aid in active acne treatment but also enhance epidermal turnover and inhibit melanin production, reducing hyperpigmentation [14]. Recent studies highlight the importance of a holistic approach to PIH management, incorporating photoprotection and adjunctive treatments such as azelaic acid and chemical peels [15].

Preventing acne triggered by skincare product misuse requires targeted education and awareness. Layton and Ravenscroft (2023) emphasize the importance of personalized skincare routines tailored to individual skin types and needs, particularly for young adults prone to acne [1]. Additionally, Goh et al. (2023) support a comprehensive skincare approach which considers underlying health conditions and the effects of environmental factors [16]. Public health initiatives that promote awareness of comedogenic ingredients, the importance of patch testing, and moderation in skincare product application could significantly reduce preventable acne cases. Future research should explore how specific cosmetic formulations contribute to acne exacerbation, particularly in genetically predisposed individuals.

The psychological burden associated with acne, as well as its long-term consequences such as scarring and PIH, should not be underestimated. Clark et al. (2018) stress the importance of addressing the psychosocial impact of acne, recognizing that a tailored treatment approach not only improves dermatological outcomes but also enhances patients’ quality of life [14]. For cases of iatrogenic acne, as presented here, a multidisciplinary approach involving dermatologists, primary care providers, and mental health professionals is essential for holistic care.

The traditional comedogenicity scale is limited by variability in study models and does not account for final product formulation or in vivo application. As highlighted by Maarouf et al. (2018), comedogenicity should be considered in the context of entire formulations and individual skin responses rather than isolated ingredients [5]. This case emphasizes the need for clinicians to consider external factors, such as the role of excessive application of skincare products on oily skin regions, when evaluating patients with acne vulgaris. Effective management requires a holistic approach, addressing both intrinsic and extrinsic contributors while customizing treatments based on an individual’s skin type and acne severity. Further research is warranted to explore the role of cosmetic products in acne development with the goal of refining prevention and treatment strategies.

4. Conclusions

Our patient developed widespread acne vulgaris on the trunk, specifically the upper back, and chest areas after excessive application of moisturizing topical creams over a short period of time. To prevent acne potentially triggered by skincare misuse, clinicians should advise patients, especially those with oily or acne-prone skin, to avoid frequent application of heavy, occlusive moisturizers on seborrheic areas such as the chest and back. Emphasis should be placed on choosing non-comedogenic formulations, applying products exclusively, and monitoring skin response. Educational counseling about proper skincare routines and patch testing new products before widespread use may help minimize iatrogenic acneiform eruptions.

Consistent with the 2024 American Academy of Dermatology (AAD) recommendations, avoidance of comedogenic skincare products is a key component of acne management, especially in individuals with oily or acne-prone skin. This case highlights the possible role of excessive application of moisturizer in exacerbating truncal acne in a predisposed individual and the importance of patient education on comedogenic ingredients with an emphasis on minimizing iatrogenic exacerbation of acne [17].