In this video blog, Joshua Zeichner, MD, discusses highlights from his lecture, Acne in 2024, on July 26, 2024, during the inaugural Elevate-Derm Alliance Summer Conference at the Westin Copley Place in Boston, Massachusetts.
In this video
In conversation with Jennifer Connor, Dr. Zeichner revisits the "chicken or the egg" question in acne and points to data showing that subclinical inflammation actually precedes the microcomedone. Biopsies of acne-prone patients revealed inflammation around the follicle even in clinically normal-appearing skin — which is why he argues for treating the entire problem area with topicals rather than spot treating, since "the best way to treat acne is to prevent it from developing to begin with." He connects this to sebum quality: acne patients not only make more oil but oil with lower linoleic acid, a precursor to ceramides. Lower ceramide levels correlate with acne severity and drive the barrier dysfunction and follicular hyperkeratinization behind breakouts — making a case for moisturizers, including those with linoleic acid.
Zeichner is firmly "team prime with the moisturizer first," noting studies show prior moisturizer application doesn't blunt retinoid efficacy while improving tolerability, and that moisturizing after can drag retinoid to unwanted areas (or try the TikTok "retinoid sandwich"). On isotretinoin, he favors twice-daily dosing given the ~21-hour half-life, stresses taking generic formulations with a fatty meal, and reminds that insufficient dosing is the number one cause of relapse. His endpoint isn't the original studies' 80% improvement but 100% clearance, treating a minimum of five months plus one month of clear skin as an "insurance policy."
- Subclinical inflammation precedes the microcomedone — treat the whole affected area with topicals instead of spot treating to prevent lesions from forming.
- It's sebum quality, not just quantity: acne patients have lower linoleic acid, which reduces ceramide production, impairs the skin barrier, and drives follicular blockages.
- Moisturize first, retinoid second — prior moisturizer application doesn't reduce retinoid efficacy and improves tolerability while keeping the medication where you want it.
- Dose isotretinoin twice daily to maintain drug levels beyond its ~21-hour half-life, and always take generic formulations with a fatty meal for absorption.
- Insufficient dosing is the top cause of relapse; aim for 100% clearance — not the older 80% endpoint — treating at least five months plus one month of clear skin.
