What are prescription topical exfoliants?

Prescription Topical Exfoliants

Prescription topical exfoliants are specialized dermatological products that accelerate skin cell turnover and include retinoids, alpha-hydroxy acids (AHAs) like glycolic acid, and beta-hydroxy acids (BHAs) like salicylic acid, available in higher concentrations than over-the-counter products.

Retinoids

Retinoids are the cornerstone of prescription topical exfoliants and are considered first-line treatment for acne vulgaris due to their multiple mechanisms of action:

• Mechanism of action:

  • Comedolytic (expel mature comedones)
  • Reduce microcomedone formation
  • Exert anti-inflammatory effects 1
  • Normalize keratinization

• Types of prescription retinoids:

  • Tretinoin (all-trans retinoic acid) - FDA approved for acne vulgaris 2
  • Adapalene (synthetic third-generation polyaromatic)
  • Tazarotene (synthetic third-generation polyaromatic)

• Clinical applications:

  • First-line treatment for most types of non-inflammatory and inflammatory acne 1, 3
  • Maintenance therapy after initial combination treatment 1
  • Long-term medication without risk of bacterial resistance 1

• Adverse effects:

  • Local reactions including erythema, dryness, itching, and stinging (primarily during early treatment phase) 1
  • Increased sun sensitivity

Alpha-Hydroxy Acids (AHAs)

Glycolic acid is the most widely used AHA in prescription formulations:

• Mechanism of action:

  • Chemical exfoliation through keratinocyte detachment
  • Activation of TRPV3 channels in keratinocytes via intracellular acidification 4
  • Promotes cell turnover

• Formulations and concentrations:

  • Available as free acids, partially neutralized, buffered, or esterified solutions
  • Prescription concentrations range from 20-70% 5
  • Very superficial peel: 30-50% glycolic acid (1-2 min application)
  • Superficial peel: 50-70% glycolic acid (2-5 min application)
  • Medium depth peel: 70% glycolic acid (3-15 min application) 5

• Clinical applications:

  • Acne vulgaris and acne scars 5
  • Photoaged skin 6
  • Ichthyosis, xerosis, actinic keratosis, seborrheic keratoses, warts, and psoriasis 7

• Treatment protocol:

  • Typically applied once every 15 days for 4-6 months 5

• Adverse effects:

  • Postinflammatory hyperpigmentation
  • Erosive blisters and scarring in higher concentrations 5
  • Increased sun sensitivity 6

Beta-Hydroxy Acids (BHAs)

Salicylic acid is the primary BHA used in prescription exfoliants:

• Mechanism of action:

  • Lipophilic properties allow penetration into sebaceous follicles
  • Keratolytic effect
  • Anti-inflammatory properties

• Formulations and concentrations:

  • Prescription concentrations of 20-30% 5
  • Very superficial peel: 20% salicylic acid
  • Superficial peel: 30% salicylic acid
  • Applied for 2-4 minutes depending on clinical response 5

• Clinical applications:

  • Primarily for comedonal acne 5
  • May have photoprotective properties compared to AHAs 7

• Adverse effects:

  • Mild stinging, discomfort, burning, erythema, and exfoliation 5
  • Less photosensitizing than AHAs 7

Contraindications and Precautions

• General contraindications:

  • Active infections or open wounds (e.g., herpes simplex, excoriations) 5
  • Isotretinoin therapy within the last 6 months 5
  • History of abnormal scar formation or delayed wound healing 5

• Patient selection considerations:

  • Psychological stability and realistic expectations 5
  • Skin type and condition (history of rosacea, seborrheic dermatitis, atopic dermatitis, psoriasis, vitiligo) 5
  • Previous facial procedures or surgeries 5

Clinical Pearls

• Topical retinoids should be considered the mainstay of therapy for acne, yet they are underprescribed (only 58.8% of dermatologists and 32.4% of non-dermatologists prescribe them) 3
• Sun protection is essential when using prescription exfoliants, particularly AHAs, which can increase photosensitivity 6
• Combination therapy with topical retinoids and antimicrobials is recommended for most acne patients due to complementary mechanisms of action 3
• The American Academy of Dermatology recommends controlling active acne before initiating scar treatment 8