User login
Tribulus terrestris
A member of the Zygophyllaceae family, Tribulus terrestris, also known as Gokshura, Gokharu, or puncture vine, is an annual herb; its aerial parts, roots, and fruits have been used in traditional medicine for anti-inflammatory, diuretic, tonic, antimicrobial, and aphrodisiac purposes for thousands of years in China, India, Pakistan, and Sudan.1-3 In modern times, the health benefits of T. terrestris have been attributed to the constituent saponins, flavonoids, alkaloids, lignins, amides, and glycosides that have been isolated and found as bioactive compounds in the plant.2-4
In an ethnobotanical survey of medicinal plants used in Nepal that was conducted in 2010 and 2011, Singh et al. found that T. terrestris was one of the 66 plant species important in the region. They also reported that it is one of the threatened species requiring conservation efforts.5 Although T. terrestris has long had a reputation for aphrodisiac qualities, critical reviews of the literature have undermined this historical reputation.1,6 Nevertheless, the botanical agent is used most often to treat infertility and loss of libido.4 More germane to the dermatologic realm, T. terrestris is thought to exhibit antioxidant, anticarcinogenic, and immunomodulatory potential, among other health benefits.4
Skin lightening activity
In a study published in 2002, Deng et al. evaluated the effects of a decoction of T. terrestris on tyrosinase activity and melanogenesis on cultured human melanocytes. They found that the amount of melanin increased when the decoction was administered in higher concentrations (optimally 1.5 mg/mL) but the effects were reversed at lower concentrations (0.5 mg/mL). Similarly, tyrosinase activity was facilitated by high concentrations of the decoction (optimally 100 mg/mL) and hindered at low concentrations (10 mg/mL). The investigators concluded that T. terrestris showed intriguing potential for use as a skin lightening agent that warranted further study.7
A mouse study performed by Yang et al. in 2006 revealed that T. terrestris extract administered orally to C57BL/6J mice resulted in a significantly higher expression of melanocyte-stimulating hormone in the hair follicles of treated mice (75%), compared with that in the control group (18.75%). The researchers concluded that T. terrestris galvanizes tyrosinase activity and fosters melanocyte increase, melanin production, and the epidermal movement of dormant melanocytes.8
Anticancer activity
Kumar et al. showed in 2006 that the aqueous extracts of T. terrestris roots and fruits displayed chemopreventive activity in male Swiss albino mice. Specifically, oral administration of T. terrestris before, during, and after papillomagenesis induced by 7, 12-Dimethylbenz(a)anthracene (DMBA) resulted in significant decreases in tumor incidence, tumor burden, and cumulative number of papillomas, as well as a significant increase in average latent period as compared with the control group treated with DMBA and croton oil.9
The next year, Neychev et al. published a study on the effects of T. terrestris–derived saponins on normal human skin fibroblasts with a focus on anticancer activities. The researchers noted that the botanical engendered a dose-dependent reduction in [3H]-thymidine incorporation into the DNA of treated fibroblasts, which was not the case for untreated controls. This and several other metrics suggested that T. terrestris poses much less toxicity to normal human skin fibroblasts than multiple previously explored cancer lines by virtue of the up-regulation and down-regulation of polyamine homeostasis, hampering proliferation, and apoptosis induction.10 
In 2012, Sisto et al. investigated the effects of T. terrestris–derived saponins on apoptosis in normal human keratinocytes exposed to UVB, as well as their antitumoral activity. They found that the saponins blunted UVB-induced apoptosis in normal human keratinocytes and did not render malignant keratinocytes more resistant to UVB in squamous cell carcinomas. The investigators concluded that their findings suggest a preventive capacity of T. terrestris against UVB-induced damage and carcinogenesis.11
Conclusion
As is the case with numerous botanical agents used for health purposes, where there’s smoke, there’s fire. That is, T. terrestris has warranted investigation for its applicability in the modern health armamentarium. I hope that conservation efforts for this plant will prevail, as much more research is necessary to determine whether it can become useful in the dermatologic realm.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Qureshi A et al. J Diet Suppl. 2014 Mar;11(1):64-79.
2. Zhu W et al. Chem Cent J. 2017 Jul 11;11(1):60.
3. Chhatre S et al. Pharmacogn Rev. 2014 Jan;8(15):45-51
4. Shahid M et al. J Biol Regul Homeost Agents. 2016 Jul-Sep;30(3):785-8.
5. Singh AG et al. J Ethnobiol Ethnomed. 2012 May 16;8:19.
6. Neychev V et al. J Ethnopharmacol. 2016 Feb 17;179:345-55.
7. Deng Y et al. Di Yi Jun Yi Da Xue Xue Bao. 2002 Nov;22(11):1017-9.
8. Yang L et al. Nan Fang Yi Ke Da Xue Xue Bao. 2006 Dec;26(12):1777-9.
9. Kumar M et al. Asian Pac J Cancer Prev. 2006 Apr-Jun;7(2):289-94.
10. Neychev VK et al. Exp Biol Med (Maywood). 2007 Jan;232(1):126-33.
11. Sisto M et al. J Photochem Photobiol B. 2012 Dec 5;117:193-201.
A member of the Zygophyllaceae family, Tribulus terrestris, also known as Gokshura, Gokharu, or puncture vine, is an annual herb; its aerial parts, roots, and fruits have been used in traditional medicine for anti-inflammatory, diuretic, tonic, antimicrobial, and aphrodisiac purposes for thousands of years in China, India, Pakistan, and Sudan.1-3 In modern times, the health benefits of T. terrestris have been attributed to the constituent saponins, flavonoids, alkaloids, lignins, amides, and glycosides that have been isolated and found as bioactive compounds in the plant.2-4
In an ethnobotanical survey of medicinal plants used in Nepal that was conducted in 2010 and 2011, Singh et al. found that T. terrestris was one of the 66 plant species important in the region. They also reported that it is one of the threatened species requiring conservation efforts.5 Although T. terrestris has long had a reputation for aphrodisiac qualities, critical reviews of the literature have undermined this historical reputation.1,6 Nevertheless, the botanical agent is used most often to treat infertility and loss of libido.4 More germane to the dermatologic realm, T. terrestris is thought to exhibit antioxidant, anticarcinogenic, and immunomodulatory potential, among other health benefits.4
Skin lightening activity
In a study published in 2002, Deng et al. evaluated the effects of a decoction of T. terrestris on tyrosinase activity and melanogenesis on cultured human melanocytes. They found that the amount of melanin increased when the decoction was administered in higher concentrations (optimally 1.5 mg/mL) but the effects were reversed at lower concentrations (0.5 mg/mL). Similarly, tyrosinase activity was facilitated by high concentrations of the decoction (optimally 100 mg/mL) and hindered at low concentrations (10 mg/mL). The investigators concluded that T. terrestris showed intriguing potential for use as a skin lightening agent that warranted further study.7
A mouse study performed by Yang et al. in 2006 revealed that T. terrestris extract administered orally to C57BL/6J mice resulted in a significantly higher expression of melanocyte-stimulating hormone in the hair follicles of treated mice (75%), compared with that in the control group (18.75%). The researchers concluded that T. terrestris galvanizes tyrosinase activity and fosters melanocyte increase, melanin production, and the epidermal movement of dormant melanocytes.8
Anticancer activity
Kumar et al. showed in 2006 that the aqueous extracts of T. terrestris roots and fruits displayed chemopreventive activity in male Swiss albino mice. Specifically, oral administration of T. terrestris before, during, and after papillomagenesis induced by 7, 12-Dimethylbenz(a)anthracene (DMBA) resulted in significant decreases in tumor incidence, tumor burden, and cumulative number of papillomas, as well as a significant increase in average latent period as compared with the control group treated with DMBA and croton oil.9
The next year, Neychev et al. published a study on the effects of T. terrestris–derived saponins on normal human skin fibroblasts with a focus on anticancer activities. The researchers noted that the botanical engendered a dose-dependent reduction in [3H]-thymidine incorporation into the DNA of treated fibroblasts, which was not the case for untreated controls. This and several other metrics suggested that T. terrestris poses much less toxicity to normal human skin fibroblasts than multiple previously explored cancer lines by virtue of the up-regulation and down-regulation of polyamine homeostasis, hampering proliferation, and apoptosis induction.10
In 2012, Sisto et al. investigated the effects of T. terrestris–derived saponins on apoptosis in normal human keratinocytes exposed to UVB, as well as their antitumoral activity. They found that the saponins blunted UVB-induced apoptosis in normal human keratinocytes and did not render malignant keratinocytes more resistant to UVB in squamous cell carcinomas. The investigators concluded that their findings suggest a preventive capacity of T. terrestris against UVB-induced damage and carcinogenesis.11
Conclusion
As is the case with numerous botanical agents used for health purposes, where there’s smoke, there’s fire. That is, T. terrestris has warranted investigation for its applicability in the modern health armamentarium. I hope that conservation efforts for this plant will prevail, as much more research is necessary to determine whether it can become useful in the dermatologic realm.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Qureshi A et al. J Diet Suppl. 2014 Mar;11(1):64-79.
2. Zhu W et al. Chem Cent J. 2017 Jul 11;11(1):60.
3. Chhatre S et al. Pharmacogn Rev. 2014 Jan;8(15):45-51
4. Shahid M et al. J Biol Regul Homeost Agents. 2016 Jul-Sep;30(3):785-8.
5. Singh AG et al. J Ethnobiol Ethnomed. 2012 May 16;8:19.
6. Neychev V et al. J Ethnopharmacol. 2016 Feb 17;179:345-55.
7. Deng Y et al. Di Yi Jun Yi Da Xue Xue Bao. 2002 Nov;22(11):1017-9.
8. Yang L et al. Nan Fang Yi Ke Da Xue Xue Bao. 2006 Dec;26(12):1777-9.
9. Kumar M et al. Asian Pac J Cancer Prev. 2006 Apr-Jun;7(2):289-94.
10. Neychev VK et al. Exp Biol Med (Maywood). 2007 Jan;232(1):126-33.
11. Sisto M et al. J Photochem Photobiol B. 2012 Dec 5;117:193-201.
A member of the Zygophyllaceae family, Tribulus terrestris, also known as Gokshura, Gokharu, or puncture vine, is an annual herb; its aerial parts, roots, and fruits have been used in traditional medicine for anti-inflammatory, diuretic, tonic, antimicrobial, and aphrodisiac purposes for thousands of years in China, India, Pakistan, and Sudan.1-3 In modern times, the health benefits of T. terrestris have been attributed to the constituent saponins, flavonoids, alkaloids, lignins, amides, and glycosides that have been isolated and found as bioactive compounds in the plant.2-4
In an ethnobotanical survey of medicinal plants used in Nepal that was conducted in 2010 and 2011, Singh et al. found that T. terrestris was one of the 66 plant species important in the region. They also reported that it is one of the threatened species requiring conservation efforts.5 Although T. terrestris has long had a reputation for aphrodisiac qualities, critical reviews of the literature have undermined this historical reputation.1,6 Nevertheless, the botanical agent is used most often to treat infertility and loss of libido.4 More germane to the dermatologic realm, T. terrestris is thought to exhibit antioxidant, anticarcinogenic, and immunomodulatory potential, among other health benefits.4
Skin lightening activity
In a study published in 2002, Deng et al. evaluated the effects of a decoction of T. terrestris on tyrosinase activity and melanogenesis on cultured human melanocytes. They found that the amount of melanin increased when the decoction was administered in higher concentrations (optimally 1.5 mg/mL) but the effects were reversed at lower concentrations (0.5 mg/mL). Similarly, tyrosinase activity was facilitated by high concentrations of the decoction (optimally 100 mg/mL) and hindered at low concentrations (10 mg/mL). The investigators concluded that T. terrestris showed intriguing potential for use as a skin lightening agent that warranted further study.7
A mouse study performed by Yang et al. in 2006 revealed that T. terrestris extract administered orally to C57BL/6J mice resulted in a significantly higher expression of melanocyte-stimulating hormone in the hair follicles of treated mice (75%), compared with that in the control group (18.75%). The researchers concluded that T. terrestris galvanizes tyrosinase activity and fosters melanocyte increase, melanin production, and the epidermal movement of dormant melanocytes.8
Anticancer activity
Kumar et al. showed in 2006 that the aqueous extracts of T. terrestris roots and fruits displayed chemopreventive activity in male Swiss albino mice. Specifically, oral administration of T. terrestris before, during, and after papillomagenesis induced by 7, 12-Dimethylbenz(a)anthracene (DMBA) resulted in significant decreases in tumor incidence, tumor burden, and cumulative number of papillomas, as well as a significant increase in average latent period as compared with the control group treated with DMBA and croton oil.9
The next year, Neychev et al. published a study on the effects of T. terrestris–derived saponins on normal human skin fibroblasts with a focus on anticancer activities. The researchers noted that the botanical engendered a dose-dependent reduction in [3H]-thymidine incorporation into the DNA of treated fibroblasts, which was not the case for untreated controls. This and several other metrics suggested that T. terrestris poses much less toxicity to normal human skin fibroblasts than multiple previously explored cancer lines by virtue of the up-regulation and down-regulation of polyamine homeostasis, hampering proliferation, and apoptosis induction.10
In 2012, Sisto et al. investigated the effects of T. terrestris–derived saponins on apoptosis in normal human keratinocytes exposed to UVB, as well as their antitumoral activity. They found that the saponins blunted UVB-induced apoptosis in normal human keratinocytes and did not render malignant keratinocytes more resistant to UVB in squamous cell carcinomas. The investigators concluded that their findings suggest a preventive capacity of T. terrestris against UVB-induced damage and carcinogenesis.11
Conclusion
As is the case with numerous botanical agents used for health purposes, where there’s smoke, there’s fire. That is, T. terrestris has warranted investigation for its applicability in the modern health armamentarium. I hope that conservation efforts for this plant will prevail, as much more research is necessary to determine whether it can become useful in the dermatologic realm.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014), as well as a New York Times Best Sellers book for consumers,“The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Qureshi A et al. J Diet Suppl. 2014 Mar;11(1):64-79.
2. Zhu W et al. Chem Cent J. 2017 Jul 11;11(1):60.
3. Chhatre S et al. Pharmacogn Rev. 2014 Jan;8(15):45-51
4. Shahid M et al. J Biol Regul Homeost Agents. 2016 Jul-Sep;30(3):785-8.
5. Singh AG et al. J Ethnobiol Ethnomed. 2012 May 16;8:19.
6. Neychev V et al. J Ethnopharmacol. 2016 Feb 17;179:345-55.
7. Deng Y et al. Di Yi Jun Yi Da Xue Xue Bao. 2002 Nov;22(11):1017-9.
8. Yang L et al. Nan Fang Yi Ke Da Xue Xue Bao. 2006 Dec;26(12):1777-9.
9. Kumar M et al. Asian Pac J Cancer Prev. 2006 Apr-Jun;7(2):289-94.
10. Neychev VK et al. Exp Biol Med (Maywood). 2007 Jan;232(1):126-33.
11. Sisto M et al. J Photochem Photobiol B. 2012 Dec 5;117:193-201.
Five common pitfalls of retailing skin care
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
Others believe that providing patients with the correct skin care product recommendations for their skin’s needs is a crucial step to improving outcomes and educating patients.
There is a wide range of challenges related to skin care retail that many physicians face. I will be running a course on Skin Care Retail at the American Society for Dermatologic Surgery meeting in October in Scottsdale, Ariz., if you want to learn more or share your opinions. I have surveyed plastic surgeons and dermatologists via LinkedIn about what they believe are some of the biggest pitfalls to retailing skin care. Here, I will share some of their insights and suggestions for overcoming these obstacles.
1. Patients are more knowledgeable about skin care than ever before
Facing an increasing number of over-the-counter skin care products available, as well as buzzwords like “organic ingredients” and “vegan,” patients are now bombarded with information from a variety of different sources. Because of this, patients come to the doctor with preconceived ideas that can affect compliance if their specific needs and beliefs are not properly addressed.
For New York plastic surgeon Sonita M. Sadio, MD, this is one of the reasons why she chooses not to sell skin care in her office.
“My practice is highly consultative, and ongoing skin care recommendations are a significant part of what I do to optimize patient outcomes,” Dr. Sadio said. “Patients are well-educated about skin care today. They know their ingredients and insist on clean formulations, free of certain ingredients, such as ‘cruelty-free’ and ‘vegan.’ Others feel deprived if they are not using an expensive product in elegant packaging. Still, others insist on drugstore favorites or ‘eco’ offerings and have their own sense of what that means. My job is to optimize the clinical outcome while also meeting these patients needs to ensure compliance.”
Not all doctors have the time, knowledge or desire to personally design each patient’s skin care regimen. Many delegate this to the staff. However, it is impossible to ensure that your staff matches patients to the proper products unless they have had extensive training on both skin care products and how to match them to the patient’s skin issues.
2. Patients are wary when the doctors sells only one product brand
Many studies have shown that, although consumers desire a choice when making purchases, they get overwhelmed if they are presented with too many options. One study showed that it is optimal to carry at least 3 brands of products. For this reason, limiting the skin care you sell to one brand or doing your own private label is not optimal.
New York dermatologist Rebecca Tamez, MD, pointed out the same problem when selling practice-specific skin care. “At my previous job, we sold skin care products directly to patients. I had no issues selling products that were readily available in drugstores or online (such as Vanicream and EltaMD). We usually sold these around the same cost as the drugstore or Amazon. However, it was harder to sell the practice-specific skin care line. I feel patients were more wary of these products.”
3. Doctors do not want to feel like salespeople
If you have read my Dermatology News columns in the past, you may know that I think it is unethical for dermatologists to not offer specific skin care advice to their patients. If patients do not get ethical and scientific recommendations from us, they will follow the advice of a friend or salesperson or purchase based on often inflated marketing claims.
Dermatologists often tell me: “I am not a cosmetic dermatologist so I do not sell skin care.” I feel strongly that general dermatologists should be giving specific written skin care recommendations for their patients too. Acne, rosacea, melasma, eczema, psoriasis, keratosis pilaris, and many other conditions will improve faster with an efficacious skin care regimen, assuming the patient is compliant with the instructions. Retailing skin care improves compliance by eliminating a few barriers to beginning the skin care regimen. I believe that the mindset of dermatologists needs to change: It is not about selling products to patients, it is about educating them on what to use and offering the products out of convenience and the desire to improve compliance.
Meadowbrook, Pa., dermatologist Michael A. Tomeo, MD, explained an obstacle faced by many dermatologists:
“I suspect, like many of my colleagues,” said Dr. Tomeo, “that I am held back in terms of salesmanship, having been trained in the traditional way. Physicians of my generation were taught to be ethical and professional and to focus on academic and clinical excellence, and salesmanship and advertising one’s services were frowned upon. It takes time to reset one’s former proclivities. Cosmeceuticals and nutraceuticals are revolutionizing the skin care world, and as experts in all things skin, we need to be well informed and offer our patients safe, effective, and cutting-edge treatments.”
4. Providers are concerned about product costs and time constraints
Providing excellent patient care and improving outcomes is at the forefront of our business, but financial concerns and time constraints prevent some doctors from offering skin care to their patients.
Rochester Hills, Mich., plastic surgeon Richard Hainer, MD, has found that “skin care is often too complex with too many products and is not very profitable.” For those reasons, Dr. Hainer has chosen not to retail skin care in his practice.
Nampa, Idaho, dermatologist Ryan S. Owsley, MD, explained that “the required minimum purchases by some of the product lines can leave the practice with expired product if it is not selling a particular line well. Cost can also be an issue for some patients in the area we are located.”
As a burn survivor and burn surgeon, Mark McDonough, MD, from Orlando “has a long history with skin care and rejuvenation. I did have a private label skin care line, including a moisturizer, a hydroquinone product, a retinol cream, and a sunscreen,” Dr. McDonough said. “However, and regrettably, I have not kept up with marketing and promotion, with most of my energy invested in trauma and disease survivors through a book, a blog, and my platform through my website.”
Doing your own product line is costly and spending the time and resources to promote it is not always possible. Buying the minimum order of products is often expensive, and you will not be able to sell them without a proven methodology in place. New products enter the market frequently, and it is expensive to always carry the latest technologies because new minimum orders must be met with each new brand that you add.
5. Selling skin care requires ongoing education
Properly recommending and retailing skin care involves physician, staff, and patient education. Unfortunately, most practices rely on training from the cosmeceutical sales reps who obviously have a brand bias. There is minimal unbiased “brand agnostic” skin care training for dermatologists and their staff. In fact, the AAD meeting has only a few skin care lectures in the program. Plastic surgeon Gaurav Bharti, MD, of Charlotte, N.C., explained that “motivating staff to help with retail skin care can be challenging. The first step is to get the staff familiar with the products with open discussions with the representatives. The next step has been to have the staff actually use the products and believe in them. Once they believe in the product, we have used an incentivization model that’s simple, transparent, and predictable.”
We are all too busy to spend adequate time with our patients, so it is critical that our staff be able to properly recommended skin care for us. We have to ensure that our staff is taking an ethical and scientific approach to skin care retail rather than a financial one. Rigorous staff training on how to match skin care products to skin type is the key to improving outcomes with skin care recommendations.
In a similar sense, Cincinnati plastic surgeon Richard Williams, MD, commented that “aestheticians often succumb to the desires of our patients to carry too many products in inventory, for which they do not have enough knowledge of the product’s benefits. This can be a very frustrating challenge.”
Conclusion
Although there are many obstacles to retailing skin care in your medical practice, the benefits that it provides to both your patients (improved outcomes) and your practice (increased profitability) far outweigh the challenges. I solved these pitfalls in my own practice by developing a standardized staff training program and skin care diagnostic software that is now used by over 100 medical practices. If you want to start retaining skin care, my advice is develop a training plan and a methodology for the recommendation and patient education process before you spend a lot of money on the required minimum product order. Feel free to contact me for advice. Alternatively, if you already do a great job of retailing skin care and want to provide tips to include in my American Society for Dermatologic Surgery course, contact me on LinkedIn or [email protected]. You can also find blogs I have written on skin care retail advice at STSFranchise.com.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
Buckwheat Extract
Native to North and East Asia, This highly adaptable plant – the most common species of which are Fagopyrum esculentum (common buckwheat or sweet buckwheat), and F. tataricum (which grows in more mountainous regions) – has acclimated to cultivation in North America, as well.1 Increasingly popular as a healthy grain option, buckwheat flour has been touted for beneficial effects on diabetes, obesity, hypertension, hypercholesterolemia, and constipation.1 It has also gained attention for its association with some allergic reactions.
Wound Healing
In 2008, van den Berg et al. performed an in vitro investigation of the antioxidant and anti-inflammatory qualities of buckwheat honey for consideration in wound healing. American buckwheat honey from New York was found to be the source of the most salient activities, with such properties attributed to its abundant phenolic components. The researchers suggested that these phenols might impart antibacterial activity, while the low pH and high free acid content of the buckwheat honey could contribute to healing wounds.4
Antioxidant Activity
The antioxidant capacity, along with other traits, characterizing the sprouts of common buckwheat (F. esculentum) and tartary buckwheat (F. tataricum) was evaluated by Liu et al. in 2008. Rutin is the main flavonoid found in both species, with fivefold higher levels identified in tartary buckwheat in this study. Ethanol extracts of tartary buckwheat also exhibited greater free radical scavenging activity and superoxide scavenging activity, compared with common buckwheat. Both buckwheat species displayed antioxidant activity on human hepatoma HepG2 cells, with tartary buckwheat more effective in diminishing cellular oxidative stress, which the authors attributed to its greater rutin and quercetin levels.5
Zhou et al. studied the protective effects of buckwheat honey on hydroxyl radical-induced DNA damage in 2012, finding that all studied honeys more effectively protected DNA in non–site specific rather than site-specific systems.6
Photoprotection
In a 2005 screening of 47 antioxidant substances and study of their effects on UV-induced lipid peroxidation, Trommer and Neubert reported that buckwheat extract significantly lowered radiation levels, as did extracts of St. John’s Wort, melissa, and sage. They concluded that their in vitro findings supported the inclusion of such ingredients in photoprotective cosmetic formulations or sunscreens pending the results of in vivo experiments with these compounds.7
In 2006, Hinneburg et al. evaluated the antioxidant and photoprotective activity of a buckwheat herb extract, also comparing its photoprotective characteristics to those of a commercial UV absorber. In an assay with 1,1-diphenyl-2-picryl-hydrazyl radical (DPPH), buckwheat extract exhibited significantly more antioxidant activity than did pure rutin, with buckwheat observed to more effectively block UV-induced peroxidation of linoleic acid as compared with rutin and the commercial UV absorber. The researchers concluded that including antioxidants such as buckwheat extract in photoprotective formulations may serve to maximize skin protection in such products.8
Buckwheat Sensitivity
Conclusion
Because it is a popular component in many diets around the world, especially Japan, Korea, Russia, and Poland, as well as other Asian and European countries, South Africa, Australia, and North America,4 it is reasonable to expect that we’ll see more research on buckwheat. For now, there are indications to suggest that more investigations are warranted to determine whether this botanical agent will have a meaningful role in the dermatologic armamentarium.
References
1. Li SQ et al. Crit Rev Food Sci Nutr. 2001 Sep;41(6):451-64.
2. Dattner AM. Dermatol Ther. 2003;16(2):106-13.
3. Hinneburg I et al. J Agric Food Chem. 2005 Jan 12;53(1):3-7.
4. van den Berg AJ et al. J Wound Care. 2008 Apr;17(4):172-4, 176-8.
5. Liu CL et al. J Agric Food Chem. 2008 Jan 9;56(1):173-8.
6. Zhou J et al. Food Chem Toxicol. 2012 Aug;50(8):2766-73.
7. Trommer H et al. J Pharm Pharm Sci. 2005 Sep 15;8(3):494-506.
8. Hinneburg I et al. Pharmazie. 2006 Mar;61(3):237-40.
9. Geiselhart S et al. Clin Exp Allergy. 2018 Feb;48(2):217-24.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
Native to North and East Asia, This highly adaptable plant – the most common species of which are Fagopyrum esculentum (common buckwheat or sweet buckwheat), and F. tataricum (which grows in more mountainous regions) – has acclimated to cultivation in North America, as well.1 Increasingly popular as a healthy grain option, buckwheat flour has been touted for beneficial effects on diabetes, obesity, hypertension, hypercholesterolemia, and constipation.1 It has also gained attention for its association with some allergic reactions.
Wound Healing
In 2008, van den Berg et al. performed an in vitro investigation of the antioxidant and anti-inflammatory qualities of buckwheat honey for consideration in wound healing. American buckwheat honey from New York was found to be the source of the most salient activities, with such properties attributed to its abundant phenolic components. The researchers suggested that these phenols might impart antibacterial activity, while the low pH and high free acid content of the buckwheat honey could contribute to healing wounds.4
Antioxidant Activity
The antioxidant capacity, along with other traits, characterizing the sprouts of common buckwheat (F. esculentum) and tartary buckwheat (F. tataricum) was evaluated by Liu et al. in 2008. Rutin is the main flavonoid found in both species, with fivefold higher levels identified in tartary buckwheat in this study. Ethanol extracts of tartary buckwheat also exhibited greater free radical scavenging activity and superoxide scavenging activity, compared with common buckwheat. Both buckwheat species displayed antioxidant activity on human hepatoma HepG2 cells, with tartary buckwheat more effective in diminishing cellular oxidative stress, which the authors attributed to its greater rutin and quercetin levels.5
Zhou et al. studied the protective effects of buckwheat honey on hydroxyl radical-induced DNA damage in 2012, finding that all studied honeys more effectively protected DNA in non–site specific rather than site-specific systems.6
Photoprotection
In a 2005 screening of 47 antioxidant substances and study of their effects on UV-induced lipid peroxidation, Trommer and Neubert reported that buckwheat extract significantly lowered radiation levels, as did extracts of St. John’s Wort, melissa, and sage. They concluded that their in vitro findings supported the inclusion of such ingredients in photoprotective cosmetic formulations or sunscreens pending the results of in vivo experiments with these compounds.7
In 2006, Hinneburg et al. evaluated the antioxidant and photoprotective activity of a buckwheat herb extract, also comparing its photoprotective characteristics to those of a commercial UV absorber. In an assay with 1,1-diphenyl-2-picryl-hydrazyl radical (DPPH), buckwheat extract exhibited significantly more antioxidant activity than did pure rutin, with buckwheat observed to more effectively block UV-induced peroxidation of linoleic acid as compared with rutin and the commercial UV absorber. The researchers concluded that including antioxidants such as buckwheat extract in photoprotective formulations may serve to maximize skin protection in such products.8
Buckwheat Sensitivity
Conclusion
Because it is a popular component in many diets around the world, especially Japan, Korea, Russia, and Poland, as well as other Asian and European countries, South Africa, Australia, and North America,4 it is reasonable to expect that we’ll see more research on buckwheat. For now, there are indications to suggest that more investigations are warranted to determine whether this botanical agent will have a meaningful role in the dermatologic armamentarium.
References
1. Li SQ et al. Crit Rev Food Sci Nutr. 2001 Sep;41(6):451-64.
2. Dattner AM. Dermatol Ther. 2003;16(2):106-13.
3. Hinneburg I et al. J Agric Food Chem. 2005 Jan 12;53(1):3-7.
4. van den Berg AJ et al. J Wound Care. 2008 Apr;17(4):172-4, 176-8.
5. Liu CL et al. J Agric Food Chem. 2008 Jan 9;56(1):173-8.
6. Zhou J et al. Food Chem Toxicol. 2012 Aug;50(8):2766-73.
7. Trommer H et al. J Pharm Pharm Sci. 2005 Sep 15;8(3):494-506.
8. Hinneburg I et al. Pharmazie. 2006 Mar;61(3):237-40.
9. Geiselhart S et al. Clin Exp Allergy. 2018 Feb;48(2):217-24.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
Native to North and East Asia, This highly adaptable plant – the most common species of which are Fagopyrum esculentum (common buckwheat or sweet buckwheat), and F. tataricum (which grows in more mountainous regions) – has acclimated to cultivation in North America, as well.1 Increasingly popular as a healthy grain option, buckwheat flour has been touted for beneficial effects on diabetes, obesity, hypertension, hypercholesterolemia, and constipation.1 It has also gained attention for its association with some allergic reactions.
Wound Healing
In 2008, van den Berg et al. performed an in vitro investigation of the antioxidant and anti-inflammatory qualities of buckwheat honey for consideration in wound healing. American buckwheat honey from New York was found to be the source of the most salient activities, with such properties attributed to its abundant phenolic components. The researchers suggested that these phenols might impart antibacterial activity, while the low pH and high free acid content of the buckwheat honey could contribute to healing wounds.4
Antioxidant Activity
The antioxidant capacity, along with other traits, characterizing the sprouts of common buckwheat (F. esculentum) and tartary buckwheat (F. tataricum) was evaluated by Liu et al. in 2008. Rutin is the main flavonoid found in both species, with fivefold higher levels identified in tartary buckwheat in this study. Ethanol extracts of tartary buckwheat also exhibited greater free radical scavenging activity and superoxide scavenging activity, compared with common buckwheat. Both buckwheat species displayed antioxidant activity on human hepatoma HepG2 cells, with tartary buckwheat more effective in diminishing cellular oxidative stress, which the authors attributed to its greater rutin and quercetin levels.5
Zhou et al. studied the protective effects of buckwheat honey on hydroxyl radical-induced DNA damage in 2012, finding that all studied honeys more effectively protected DNA in non–site specific rather than site-specific systems.6
Photoprotection
In a 2005 screening of 47 antioxidant substances and study of their effects on UV-induced lipid peroxidation, Trommer and Neubert reported that buckwheat extract significantly lowered radiation levels, as did extracts of St. John’s Wort, melissa, and sage. They concluded that their in vitro findings supported the inclusion of such ingredients in photoprotective cosmetic formulations or sunscreens pending the results of in vivo experiments with these compounds.7
In 2006, Hinneburg et al. evaluated the antioxidant and photoprotective activity of a buckwheat herb extract, also comparing its photoprotective characteristics to those of a commercial UV absorber. In an assay with 1,1-diphenyl-2-picryl-hydrazyl radical (DPPH), buckwheat extract exhibited significantly more antioxidant activity than did pure rutin, with buckwheat observed to more effectively block UV-induced peroxidation of linoleic acid as compared with rutin and the commercial UV absorber. The researchers concluded that including antioxidants such as buckwheat extract in photoprotective formulations may serve to maximize skin protection in such products.8
Buckwheat Sensitivity
Conclusion
Because it is a popular component in many diets around the world, especially Japan, Korea, Russia, and Poland, as well as other Asian and European countries, South Africa, Australia, and North America,4 it is reasonable to expect that we’ll see more research on buckwheat. For now, there are indications to suggest that more investigations are warranted to determine whether this botanical agent will have a meaningful role in the dermatologic armamentarium.
References
1. Li SQ et al. Crit Rev Food Sci Nutr. 2001 Sep;41(6):451-64.
2. Dattner AM. Dermatol Ther. 2003;16(2):106-13.
3. Hinneburg I et al. J Agric Food Chem. 2005 Jan 12;53(1):3-7.
4. van den Berg AJ et al. J Wound Care. 2008 Apr;17(4):172-4, 176-8.
5. Liu CL et al. J Agric Food Chem. 2008 Jan 9;56(1):173-8.
6. Zhou J et al. Food Chem Toxicol. 2012 Aug;50(8):2766-73.
7. Trommer H et al. J Pharm Pharm Sci. 2005 Sep 15;8(3):494-506.
8. Hinneburg I et al. Pharmazie. 2006 Mar;61(3):237-40.
9. Geiselhart S et al. Clin Exp Allergy. 2018 Feb;48(2):217-24.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
Sesamol
The protective effects of the antioxidative compound sesamol against radiation were reported as early as 1991.1 The water-soluble lignan sesamol, a natural phenolic compound derived from Sesamum indicum (sesame) seed oil, has since become known as a potent antioxidant with significant anticancer potential.2,3 As a constituent found in food oils such as sesame and sunflower oil, sesamol has been studied for the dietary benefits that it has been said to impart. Sesame oil, in particular, has been used in Ayurveda, traditional Chinese medicine, as well as in folk medicine in Nigeria and other African countries.Data on its antioxidant and chemopreventive properties also have prompted investigations into its potential in the dermatologic realm because sesamol has demonstrated an increasingly wide array of cutaneous applications.
Antibacterial effects
In 2007, Bankole et al. ascertained the synergistic antimicrobial properties of the essential oils and lignans found in the leaf extracts of S. radiatum and S. indicum. Phytochemical screening of methanolic extracts revealed the presence of phenolic compounds such as the potent antioxidants sesamol, sesamolin, and sesamin, as well as carboxylic acids. Methanolic and ethanolic extracts were shown to exhibit broad-spectrum antimicrobial effects against all of the pathogens tested except Streptococcus pneumoniae (methanolic extracts) and Staphylococcus aureus (ethanolic extracts). The investigators concluded that their results buttressed long-held traditional claims in multiple regions in Nigeria where consumption of sesame leaf extracts has been known to confer antibacterial effects with effectiveness reported for common skin infections.4
Anticancer activity
Kapadia et al. studied the dietary components resveratrol, sesamol, sesame oil, and sunflower oil in various protocols, including a murine two-stage skin cancer model, for their potential as cancer chemopreventive agents. In this 2002 study, the mouse skin tumor model, sesamol was found to provide a 50% reduction in skin papillomas at 20 weeks after promotion with 12-O-tetradecanoylphorbol 13-acetate. The researchers concluded that all of the dietary constituents appeared to provide chemopreventive effects.5
In 2010, Ramachandran et al. observed that pretreating human skin dermal fibroblast adult cells with sesamol before irradiation with UVB yielded significant reductions in cytotoxicity, intracellular reactive oxygen species levels, lipid peroxidation, and apoptosis. In noting increases in enzymatic and nonenzymatic antioxidant activity in sesamol-pretreated UVB-exposed fibroblasts, the investigators ascribed the apparent protective effects of sesamol to its antioxidant scavenging of reactive oxygen species.6
Seven years later, Bhardwaj et al. evaluated the chemopreventive efficacy of free and encapsulated sesamol in a 7,12-dimethylbenz[a]-anthracene–induced skin cancer animal model. The investigators found that in both forms sesamol significantly reduced tumor burden and lipid peroxidation while raising antioxidant levels. This resulted in the inhibition of skin tumor development and promotion. Apoptosis in tumor cells also was found to result from the down-regulation of Bcl-2 and stimulation of Bcl-2–associated X protein expression from administration of both free and encapsulated sesamol. Furthermore, the irritant qualities of sesamol were mitigated by encapsulation, which also aided in direct targeting of the skin.2
Potential cosmeceutical applications: Anti-aging and skin-whitening activity
In 2006, Sharma and Kaur demonstrated in mouse skin, through biochemical and histopathologic evaluations, that a topical sesamol formulation was effective in preventing photodamage (such as alterations in skin integrity, lesions, ulcers) from chronic UV exposure. They suggested the merits of further testing and consideration of sesamol as an antiaging agent.7
Almost a decade later, Srisayam et al. conducted a systematic study of the antimelanogenic and skin protective activities of sesamol. They found that sesamol exhibited significant scavenging activity of the 2,2-Diphenyl-1-picrylhydrazyl hydrate radical with an IC50 value less than 14.48 mcm. The antioxidant also suppressed lipid peroxidation (IC50 value of 6.15 mcm), and displayed a whitening effect via mushroom tyrosinase inhibition as well as inhibition of cellular tyrosinase. In noting the potent antioxidant and antityrosinase activity in comparison to the positive control – kojic acid and beta-arbutin – the researchers highlighted the potential cosmeceutical applications of sesamol.8
Baek and Lee showed in 2015 that sesamol potently suppressed melanin biosynthesis by down-regulating tyrosinase activity and regulating gene expression of melanogenesis-related proteins via microphthalmia-associated transcription factor (MITF) activity modulation. They concluded that sesamol warrants attention in the cosmetic realm as a new skin-whitening agent.9
Formulation issues
Earlier that year, Geetha et al. confirmed the apoptotic characteristics of sesamol in in vitro antiproliferative and DNA-fragmentation studies in HL60 cell lines. Because of its small size, low molecular weight, and easy permeability, its viability in topical applications is considered minimal. The investigators addressed this issue by preparing sesamol-loaded solid-lipid nanoparticles, which, when applied in a cream base in mice, revealed significant retention in the skin. Its use in in vivo anticancer studies performed on tumor production induced by 12-O-tetradecanoylphorbol 13-acetate and initiated by benzo(a)pyrene in mouse epidermis resulted in the normalization of skin cancers.10
More recently, Puglia et al. set out to improve the delivery of the benefits of sesamol to the skin by developing a nanostructured lipid carrier for topical administration. They synthesized two different carrier systems and performed an in vitro percutaneous absorption study in excised human skin to determine antioxidant activity. The carrier systems differed by oil phase: One contained Miglyol 812 (nanostructured lipid carrier–M) and the other contained sesame oil (nanostructured lipid carrier–PLUS). Greater encapsulation efficiency was reported when sesame oil was employed as the oil phase, but both products displayed the capacity in vitro to control the rate of sesamol diffusion through the skin, compared with reference preparations. Both formulations also showed the extended antioxidant activity of sesamol, particularly the nanostructured lipid carrier–PLUS.3
Conclusion
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Sato Y et al. Yakugaku Zasshi. 1991 Jan;111(1):51-8.
2. Bhardwaj R et al. Anticancer Agents Med Chem. 2017;17(5):726-33.
3. Puglia C et al. Planta Med. 2017 Mar;83(5):398-404.
4. Bankole MA et al. Afr J Tradit Complement Altern Med. 2007; 4(4): 427-33.
5. Kapadia GJ et al. Pharmacol Res. 2002 Jun;45(6):499-505.
6. Ramachandran S et al. Arch Dermatol Res. 2010 Dec;302(10):733-44.
7. Sharma S and Kaur IP. Int J Dermatol. 2006 Mar;45(3):200-8.
8. Srisayam M et al. J Cosmet Sci. 2014 Mar-Apr;65(2):69-79.
9. Baek SH and Lee SH. Exp Dermatol. 2015 Oct;24(10):761-6.
10. Geetha T et al. J Drug Target. 2015 Feb;23(2):159-69.
The protective effects of the antioxidative compound sesamol against radiation were reported as early as 1991.1 The water-soluble lignan sesamol, a natural phenolic compound derived from Sesamum indicum (sesame) seed oil, has since become known as a potent antioxidant with significant anticancer potential.2,3 As a constituent found in food oils such as sesame and sunflower oil, sesamol has been studied for the dietary benefits that it has been said to impart. Sesame oil, in particular, has been used in Ayurveda, traditional Chinese medicine, as well as in folk medicine in Nigeria and other African countries.Data on its antioxidant and chemopreventive properties also have prompted investigations into its potential in the dermatologic realm because sesamol has demonstrated an increasingly wide array of cutaneous applications.
Antibacterial effects
In 2007, Bankole et al. ascertained the synergistic antimicrobial properties of the essential oils and lignans found in the leaf extracts of S. radiatum and S. indicum. Phytochemical screening of methanolic extracts revealed the presence of phenolic compounds such as the potent antioxidants sesamol, sesamolin, and sesamin, as well as carboxylic acids. Methanolic and ethanolic extracts were shown to exhibit broad-spectrum antimicrobial effects against all of the pathogens tested except Streptococcus pneumoniae (methanolic extracts) and Staphylococcus aureus (ethanolic extracts). The investigators concluded that their results buttressed long-held traditional claims in multiple regions in Nigeria where consumption of sesame leaf extracts has been known to confer antibacterial effects with effectiveness reported for common skin infections.4
Anticancer activity
Kapadia et al. studied the dietary components resveratrol, sesamol, sesame oil, and sunflower oil in various protocols, including a murine two-stage skin cancer model, for their potential as cancer chemopreventive agents. In this 2002 study, the mouse skin tumor model, sesamol was found to provide a 50% reduction in skin papillomas at 20 weeks after promotion with 12-O-tetradecanoylphorbol 13-acetate. The researchers concluded that all of the dietary constituents appeared to provide chemopreventive effects.5
In 2010, Ramachandran et al. observed that pretreating human skin dermal fibroblast adult cells with sesamol before irradiation with UVB yielded significant reductions in cytotoxicity, intracellular reactive oxygen species levels, lipid peroxidation, and apoptosis. In noting increases in enzymatic and nonenzymatic antioxidant activity in sesamol-pretreated UVB-exposed fibroblasts, the investigators ascribed the apparent protective effects of sesamol to its antioxidant scavenging of reactive oxygen species.6
Seven years later, Bhardwaj et al. evaluated the chemopreventive efficacy of free and encapsulated sesamol in a 7,12-dimethylbenz[a]-anthracene–induced skin cancer animal model. The investigators found that in both forms sesamol significantly reduced tumor burden and lipid peroxidation while raising antioxidant levels. This resulted in the inhibition of skin tumor development and promotion. Apoptosis in tumor cells also was found to result from the down-regulation of Bcl-2 and stimulation of Bcl-2–associated X protein expression from administration of both free and encapsulated sesamol. Furthermore, the irritant qualities of sesamol were mitigated by encapsulation, which also aided in direct targeting of the skin.2
Potential cosmeceutical applications: Anti-aging and skin-whitening activity
In 2006, Sharma and Kaur demonstrated in mouse skin, through biochemical and histopathologic evaluations, that a topical sesamol formulation was effective in preventing photodamage (such as alterations in skin integrity, lesions, ulcers) from chronic UV exposure. They suggested the merits of further testing and consideration of sesamol as an antiaging agent.7
Almost a decade later, Srisayam et al. conducted a systematic study of the antimelanogenic and skin protective activities of sesamol. They found that sesamol exhibited significant scavenging activity of the 2,2-Diphenyl-1-picrylhydrazyl hydrate radical with an IC50 value less than 14.48 mcm. The antioxidant also suppressed lipid peroxidation (IC50 value of 6.15 mcm), and displayed a whitening effect via mushroom tyrosinase inhibition as well as inhibition of cellular tyrosinase. In noting the potent antioxidant and antityrosinase activity in comparison to the positive control – kojic acid and beta-arbutin – the researchers highlighted the potential cosmeceutical applications of sesamol.8
Baek and Lee showed in 2015 that sesamol potently suppressed melanin biosynthesis by down-regulating tyrosinase activity and regulating gene expression of melanogenesis-related proteins via microphthalmia-associated transcription factor (MITF) activity modulation. They concluded that sesamol warrants attention in the cosmetic realm as a new skin-whitening agent.9
Formulation issues
Earlier that year, Geetha et al. confirmed the apoptotic characteristics of sesamol in in vitro antiproliferative and DNA-fragmentation studies in HL60 cell lines. Because of its small size, low molecular weight, and easy permeability, its viability in topical applications is considered minimal. The investigators addressed this issue by preparing sesamol-loaded solid-lipid nanoparticles, which, when applied in a cream base in mice, revealed significant retention in the skin. Its use in in vivo anticancer studies performed on tumor production induced by 12-O-tetradecanoylphorbol 13-acetate and initiated by benzo(a)pyrene in mouse epidermis resulted in the normalization of skin cancers.10
More recently, Puglia et al. set out to improve the delivery of the benefits of sesamol to the skin by developing a nanostructured lipid carrier for topical administration. They synthesized two different carrier systems and performed an in vitro percutaneous absorption study in excised human skin to determine antioxidant activity. The carrier systems differed by oil phase: One contained Miglyol 812 (nanostructured lipid carrier–M) and the other contained sesame oil (nanostructured lipid carrier–PLUS). Greater encapsulation efficiency was reported when sesame oil was employed as the oil phase, but both products displayed the capacity in vitro to control the rate of sesamol diffusion through the skin, compared with reference preparations. Both formulations also showed the extended antioxidant activity of sesamol, particularly the nanostructured lipid carrier–PLUS.3
Conclusion
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Sato Y et al. Yakugaku Zasshi. 1991 Jan;111(1):51-8.
2. Bhardwaj R et al. Anticancer Agents Med Chem. 2017;17(5):726-33.
3. Puglia C et al. Planta Med. 2017 Mar;83(5):398-404.
4. Bankole MA et al. Afr J Tradit Complement Altern Med. 2007; 4(4): 427-33.
5. Kapadia GJ et al. Pharmacol Res. 2002 Jun;45(6):499-505.
6. Ramachandran S et al. Arch Dermatol Res. 2010 Dec;302(10):733-44.
7. Sharma S and Kaur IP. Int J Dermatol. 2006 Mar;45(3):200-8.
8. Srisayam M et al. J Cosmet Sci. 2014 Mar-Apr;65(2):69-79.
9. Baek SH and Lee SH. Exp Dermatol. 2015 Oct;24(10):761-6.
10. Geetha T et al. J Drug Target. 2015 Feb;23(2):159-69.
The protective effects of the antioxidative compound sesamol against radiation were reported as early as 1991.1 The water-soluble lignan sesamol, a natural phenolic compound derived from Sesamum indicum (sesame) seed oil, has since become known as a potent antioxidant with significant anticancer potential.2,3 As a constituent found in food oils such as sesame and sunflower oil, sesamol has been studied for the dietary benefits that it has been said to impart. Sesame oil, in particular, has been used in Ayurveda, traditional Chinese medicine, as well as in folk medicine in Nigeria and other African countries.Data on its antioxidant and chemopreventive properties also have prompted investigations into its potential in the dermatologic realm because sesamol has demonstrated an increasingly wide array of cutaneous applications.
Antibacterial effects
In 2007, Bankole et al. ascertained the synergistic antimicrobial properties of the essential oils and lignans found in the leaf extracts of S. radiatum and S. indicum. Phytochemical screening of methanolic extracts revealed the presence of phenolic compounds such as the potent antioxidants sesamol, sesamolin, and sesamin, as well as carboxylic acids. Methanolic and ethanolic extracts were shown to exhibit broad-spectrum antimicrobial effects against all of the pathogens tested except Streptococcus pneumoniae (methanolic extracts) and Staphylococcus aureus (ethanolic extracts). The investigators concluded that their results buttressed long-held traditional claims in multiple regions in Nigeria where consumption of sesame leaf extracts has been known to confer antibacterial effects with effectiveness reported for common skin infections.4
Anticancer activity
Kapadia et al. studied the dietary components resveratrol, sesamol, sesame oil, and sunflower oil in various protocols, including a murine two-stage skin cancer model, for their potential as cancer chemopreventive agents. In this 2002 study, the mouse skin tumor model, sesamol was found to provide a 50% reduction in skin papillomas at 20 weeks after promotion with 12-O-tetradecanoylphorbol 13-acetate. The researchers concluded that all of the dietary constituents appeared to provide chemopreventive effects.5
In 2010, Ramachandran et al. observed that pretreating human skin dermal fibroblast adult cells with sesamol before irradiation with UVB yielded significant reductions in cytotoxicity, intracellular reactive oxygen species levels, lipid peroxidation, and apoptosis. In noting increases in enzymatic and nonenzymatic antioxidant activity in sesamol-pretreated UVB-exposed fibroblasts, the investigators ascribed the apparent protective effects of sesamol to its antioxidant scavenging of reactive oxygen species.6
Seven years later, Bhardwaj et al. evaluated the chemopreventive efficacy of free and encapsulated sesamol in a 7,12-dimethylbenz[a]-anthracene–induced skin cancer animal model. The investigators found that in both forms sesamol significantly reduced tumor burden and lipid peroxidation while raising antioxidant levels. This resulted in the inhibition of skin tumor development and promotion. Apoptosis in tumor cells also was found to result from the down-regulation of Bcl-2 and stimulation of Bcl-2–associated X protein expression from administration of both free and encapsulated sesamol. Furthermore, the irritant qualities of sesamol were mitigated by encapsulation, which also aided in direct targeting of the skin.2
Potential cosmeceutical applications: Anti-aging and skin-whitening activity
In 2006, Sharma and Kaur demonstrated in mouse skin, through biochemical and histopathologic evaluations, that a topical sesamol formulation was effective in preventing photodamage (such as alterations in skin integrity, lesions, ulcers) from chronic UV exposure. They suggested the merits of further testing and consideration of sesamol as an antiaging agent.7
Almost a decade later, Srisayam et al. conducted a systematic study of the antimelanogenic and skin protective activities of sesamol. They found that sesamol exhibited significant scavenging activity of the 2,2-Diphenyl-1-picrylhydrazyl hydrate radical with an IC50 value less than 14.48 mcm. The antioxidant also suppressed lipid peroxidation (IC50 value of 6.15 mcm), and displayed a whitening effect via mushroom tyrosinase inhibition as well as inhibition of cellular tyrosinase. In noting the potent antioxidant and antityrosinase activity in comparison to the positive control – kojic acid and beta-arbutin – the researchers highlighted the potential cosmeceutical applications of sesamol.8
Baek and Lee showed in 2015 that sesamol potently suppressed melanin biosynthesis by down-regulating tyrosinase activity and regulating gene expression of melanogenesis-related proteins via microphthalmia-associated transcription factor (MITF) activity modulation. They concluded that sesamol warrants attention in the cosmetic realm as a new skin-whitening agent.9
Formulation issues
Earlier that year, Geetha et al. confirmed the apoptotic characteristics of sesamol in in vitro antiproliferative and DNA-fragmentation studies in HL60 cell lines. Because of its small size, low molecular weight, and easy permeability, its viability in topical applications is considered minimal. The investigators addressed this issue by preparing sesamol-loaded solid-lipid nanoparticles, which, when applied in a cream base in mice, revealed significant retention in the skin. Its use in in vivo anticancer studies performed on tumor production induced by 12-O-tetradecanoylphorbol 13-acetate and initiated by benzo(a)pyrene in mouse epidermis resulted in the normalization of skin cancers.10
More recently, Puglia et al. set out to improve the delivery of the benefits of sesamol to the skin by developing a nanostructured lipid carrier for topical administration. They synthesized two different carrier systems and performed an in vitro percutaneous absorption study in excised human skin to determine antioxidant activity. The carrier systems differed by oil phase: One contained Miglyol 812 (nanostructured lipid carrier–M) and the other contained sesame oil (nanostructured lipid carrier–PLUS). Greater encapsulation efficiency was reported when sesame oil was employed as the oil phase, but both products displayed the capacity in vitro to control the rate of sesamol diffusion through the skin, compared with reference preparations. Both formulations also showed the extended antioxidant activity of sesamol, particularly the nanostructured lipid carrier–PLUS.3
Conclusion
Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Sato Y et al. Yakugaku Zasshi. 1991 Jan;111(1):51-8.
2. Bhardwaj R et al. Anticancer Agents Med Chem. 2017;17(5):726-33.
3. Puglia C et al. Planta Med. 2017 Mar;83(5):398-404.
4. Bankole MA et al. Afr J Tradit Complement Altern Med. 2007; 4(4): 427-33.
5. Kapadia GJ et al. Pharmacol Res. 2002 Jun;45(6):499-505.
6. Ramachandran S et al. Arch Dermatol Res. 2010 Dec;302(10):733-44.
7. Sharma S and Kaur IP. Int J Dermatol. 2006 Mar;45(3):200-8.
8. Srisayam M et al. J Cosmet Sci. 2014 Mar-Apr;65(2):69-79.
9. Baek SH and Lee SH. Exp Dermatol. 2015 Oct;24(10):761-6.
10. Geetha T et al. J Drug Target. 2015 Feb;23(2):159-69.
Skin care product layering affects efficacy and outcomes of regimens
Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.
The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.1 However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure. 
Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.
Efficacy and compliance in product layering
. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.
Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.2 If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
The role of cleansers
Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.3 For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.
The role of eye products
Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.
Improving efficacy of treatment products
Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.4 However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.
The role of moisturizers
Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.
Retinoids
When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.
Selecting across brands and applying products in the right order
Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.
Conclusion
Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.
2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.
4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.
Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.
The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.1 However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure.
Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.
Efficacy and compliance in product layering
. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.
Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.2 If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
The role of cleansers
Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.3 For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.
The role of eye products
Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.
Improving efficacy of treatment products
Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.4 However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.
The role of moisturizers
Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.
Retinoids
When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.
Selecting across brands and applying products in the right order
Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.
Conclusion
Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.
2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.
4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.
Dermatologists are well suited to understand cosmeceutical science and the benefits of particular cosmeceutical products – especially if they are readers of this column. However, there is another critical thought process that must be undertaken when designing an efficacious skin care regimen for patients: Topical products should be applied in a particular order to maximize efficacy. This is because cosmeceutical ingredients interact with, change each other, and are affected by temperature, pH, humidity, and the microbiome in which they are in contact. This column focuses on the factors that should be considered when recommending skin care regimens to patients and in which order to apply topical products.
The chemistry of ingredients and how they interact is well understood by personal care product formulators. I think of formulators as chefs who are using ingredients and placing them in the formulation in a well-defined order under controlled circumstances that affect the final product. For example, ceramides are used in barrier repair moisturizers. The right form of ceramide must be chosen and used with the 1:1:1 ratio of ceramides, fatty acids, and cholesterol for the product to be effective at repairing the barrier.1 However, the order of when the ceramides are added to the product formula also impacts efficacy. Waxy ceramides and cholesterol require heat to liquefy and form the proper mixture with the other ingredients. Too much heat can damage fatty acids. Also, heat can inactivate finicky active ingredients such as vitamins C and E. For this reason, the ceramides and cholesterol are often incorporated first, allowing the formula to cool before the active heat labile ingredients are added. The speed at which something is mixed can generate heat and affect the final preparations, so temperature is an important consideration at all steps in the formulation procedure.
Just as the order of creating formulations affects the final product, the order of product placement on the skin influences skin care product efficacy. If a low pH skin care product (such as a glycolic acid cleanser) is used on the skin, this is going to affect the efficacy and safety of the product that is applied next to the skin. Such a chemical phenomenon should be considered when designing the order of product applications when designing a skin care regimen, particularly when incorporating ingredients that are known to interact with other ingredients, such as benzoyl peroxide, retinoids, hydroxy acids, hydroquinone, vitamin C, and peptides.
Efficacy and compliance in product layering
. Acne treatments are a good example. Patients are often prescribed a retinoid, benzoyl peroxide, topical antibiotic, and/or salicylic acid treatment product for acne. If the proper cleansers and moisturizers are not chosen, the patient will be more likely to develop redness and scaling and become noncompliant.
Compliance is a concerning issue to dermatologists because studies have shown that 95% of people underdose and one out of every three prescriptions is not even filled.2 If patients develop side effects, they are more likely to underdose or stop the treatment. Prescribing the proper cleanser and moisturizer to accompany treatment products will ease side effects and increase compliance. Several studies have demonstrated that the best way to increase compliance is to provide patients with written instructions, so they understand the proper order in which to apply products.
The role of cleansers
Cleansers can alter the pH of the skin, loosen attachments between cells, remove lipids – and disrupt the bilayer protective membrane, desquamate layers from the stratum corneum, and influence the penetrability of the skin for the next topical product that is applied. Therefore, cleansers should be selected based on the products that will follow them in the regimen. In addition, cleansers should be chosen according to the patient’s Baumann Skin Type.3 For example, cleansers for use on oily skin should have the ability to remove excess sebum on the skin while cleansers designed for dry skin would not remove as many lipids from the skin. Washing skin with a foaming cleanser can disrupt the skin barrier, allowing increased penetration of the treatment product that follows it. Oleic acid, hyaluronic acid, stearic acid, and other lipids are among the ingredients that influence skin penetration. Cleansers should precede treatment products and should be designed to increase efficacy of the treatment product. For this reason, every ingredient and characteristic of the chosen cleanser is important.
The role of eye products
Eye products treat issues such as dryness, puffiness, fine lines, and dark circles. However, they also play an overlooked role of protecting the thin delicate eye area from the treatment product. Using an eye product, especially one with protective ingredients such as barrier repair lipids, will help the patient tolerate the potentially irritating treatment product that follows the eye product. At night, the treatment product ingredients can get on the pillowcase and transfer to the upper and lower eyelids. Use of a protective eye product before bedtime can prevent the accompanying irritation. For example, acne patients often develop redness at the corners of the eyes when using benzoyl peroxide or a retinoid at night. Applying these medications after an eye cream can reduce this side effect.
Improving efficacy of treatment products
Treatments products are defined as corrective products targeted to skin issues such as acne, rosacea, melasma, dryness, skin cancer, eczema, psoriasis, and photoaging. The entire skin care regimen should be designed to enhance efficacy and decrease side effects of the treatment products. Treatment products may be cosmeceuticals, OTC medications, or prescription medications. These products must be able to reach their target in the proper chemical structure to be effective. Each ingredient has various constraints and quirks that should be considered. One well known example is ascorbic acid (vitamin C). Ascorbic acid is a treatment product for skin pigmentation and skin aging that is well known to have specific needs to work properly. Sheldon Pinnell, MD, led multiple investigations demonstrating that the maximum absorption of ascorbic acid occurs at a pH of 2-2.5. He showed that ascorbic acid products should be formulated at a pH of 2-2.5.4 However, applying these on skin that has just been cleansed with a soap cleanser with a pH of 9 will raise the skin’s pH and decrease the absorption of ascorbic acid. Having the patient cleanse with a low pH cleanser such as salicylic or glycolic acid cleanser (usually a pH of 2.5-3.5) will lower the pH of the skin and promote absorption of vitamin C.
The role of moisturizers
Moisturizers have many duties, including hydrating the skin, protecting the skin, and delivering important ingredients to the skin. However, moisturizers have a less discussed role of improving the efficacy of the treatment product that is applied beforehand. Moisturizers often contain oleic acid, hyaluronic acid, or other fatty acids that can increase penetration of other skin care ingredients. In addition, many moisturizers provide an occlusive effect that helps increase penetration. They also help protect the underlying treatment product from getting wiped off on a pillowcase or into the environment. In other words, moisturizers “seal in” the treatment product. Some moisturizing ingredients such as heparan sulfate may affect how well the skin cells “hear” and respond to signals elicited by the treatment products. For this reason, moisturizers should also be chosen to improve the efficacy of the treatment product.
Retinoids
When using retinoids for the first time in a patient, applying them last on top of the moisturizer can reduce the incidence of side effects and increase compliance. Retinoids, unlike other ingredients, penetrate easily into the deeper layer of the epidermis. Layering them on top of a moisturizer can help titrate retinoid absorption. The moisturizer can be chosen to slow or increase penetration of retinoids. Retinoids should always be used at nighttime because many of them, especially retinol and tretinoin, are easily broken down by ultraviolet light exposure.
Selecting across brands and applying products in the right order
Manufacturers rarely perform research on a complete regimen, but rather on individual products. Dermatologists then are left to figure this out on their own. I recommend choosing the best technologies from each brand based on the patient’s Baumann Skin Type and combining them using the recommended layering technique. I choose the best “hero” products from the various brands and layer them in a sequence that increases efficacy of all of the products. I then test the entire regimen on patients to figure out what combinations have the best efficacy and fewest side effects. Once I solve this “regimen puzzle,” I program software to automatically generate the step-by-step regimen instructions by Baumann Skin Type so that I do not have to rethink this complicated subject matter with every patient. I have developed over 3,300 distinct regimens so I am certain that my patients will get the proper skin care regimen advice from me or any of my staff.
Conclusion
Dermatologists can make a significant difference in their patients’ long-term skin care health by assisting them in identifying the proper skin care formulations for their individual skin type and guiding them as to how much, and in which order, to apply the products in their personalized skin care regimen. Patients will not remember what you told them and will confuse the order in which products should be used. For this reason, providing a written step-by-step skin care regimen is paramount to ensuring patient compliance.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at [email protected].
References
1. Man MQ M et al. Optimization of physiological lipid mixtures for barrier repair. J Invest Dermatol. 1996 May;106(5):1096-101.
2. Storm A et al. One in 3 prescriptions are never redeemed: Primary nonadherence in an outpatient clinic. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
3. Baumann LS. The Baumann Skin Typing System, in Farage MA et al. “Textbook of Aging Skin.” Springer-Verlag Berlin Heidelberg, 2017, pp. 1579-94.
4. Pinnell SR et al. Topical L-ascorbic acid: Percutaneous absorption studies. Dermatol Surg. 2001 Feb; 27(2):137-42.
The role of defensins in treating skin aging
Most skin-aging treatments work by prodding old fibroblasts and keratinocytes to accelerate the production of important cellular components. For example, retinoids act on retinoic acid receptors to activate collagen genes and deactivate collagenase genes. Glycolic acid, ascorbic acid, and certain growth factors stimulate synthesis of collagen by fibroblasts. Older fibroblasts and keratinocytes are sluggish for many reasons; they do not “hear” signals as well as younger cells do. Glycosaminoglycans such as heparan sulfate can help cells hear these signals. Heparan sulfate, for example, assists in the delivery of growth factors to cells, stabilizes them, and presents them to the receptors on the keratinocytes and fibroblasts, and amplifies cellular response to these factors.
A new angle in antiaging skin care is to create new keratinocytes rather than to stimulate old cells. For the last decade, personal care companies have touted the benefit of putting stem cells in cosmeceuticals, claiming that these cells would rejuvenate skin. However, this proved to be unsubstantiated marketing hype because the stem cells were plant derived (often from apples), had poor shelf life, and could not intercalate between the native skin cells and work with them to have any effect. Stems cells in cosmeceuticals became a point of disdain for savvy scientists.
Stem cells
Wounding the skin stimulates LGR6+ stem cells. This occurs when neutrophils in the immune system release defensins in response to injury, and, in turn, defensins activate LGR6+ stem cells. Situated above the follicular bulge, these cells are reported to have the capacity to synthesize all cutaneous cell lineages, including sebaceous gland and interfollicular epidermal cells.1,2 There are no specific studies that show that the LGR6+ cells generate new fibroblasts, but it seems likely. Transplantation of LGR6+ stem cells into the skin results in increased wound healing, hair follicle genesis, and angiogenesis.3 LGR6+ stem cells repopulate the epidermis by creating new basal stem cells. In regards to skin rejuvenation, it is clear that activated LGR6+ stems cells produce new, younger-acting keratinocytes in the epidermis.
Peptides
Defensin is a peptide. Peptides are short amino acid chains. These important substances are challenging to incorporate into topical formulations for various reasons, including stabilization difficulty, interaction with other molecules, and poor penetration (greater than 500 Dalton molecular weight). For these reasons, many peptide-containing formulations do not have efficacy. Attempts are underway to better develop or modify peptide products to enhance solubility, achieve better penetration, and target increased receptor activity. Defensins are peptides, which makes them difficult to formulate in a topical product. Special steps must be taken in the formulation process to stabilize defensin and allow penetration into the hair follicle where the LGR6+ cells reside. Fortunately, it is easier for a peptide to target the hair follicle because it can traverse through the “pore” – than it is to get a peptide to reach the fibroblasts in the dermis.
Defensins
Defensins, or human beta-defensins, are host defense peptides that exhibit antimicrobial activities against numerous bacteria.4 LGR6+ stem cells, which are dormant until they are activated to respond to damage, are stimulated by defensins. Defensins have been shown to stimulate keratinocyte proliferation, migration, and wound healing. (3) **Human alpha-defensin 5 peptide has also been shown to enhance wound healing, increasing LGR5+ and LGR6+ stem cell migration in the wound bed.(1)***
When formulated in a manner that allows for stability and penetration into the hair follicle where the LGR6+ stem cells reside, defensin formulations can be applied topically. A product sold as DefenAge uses a patented formulation that uses albumin, a large and stable protein, to stabilize defensin and act as a carrier molecule while helping the defensin maintain its integrity and extend shelf life in the serum base. The albumin/defensin complex is incorporated into liposomes to prevent other ingredients in the cosmetic base from interacting with the peptide and to enhance delivery to the LGR6+ target cell.
The role of defensins in treating skin aging
- Old fibroblast and keratinocytes are sluggish and lazy.
- Old cells do not “hear” signals as well as younger cells.
- LGR6+ stem cells repopulate the epidermis with new, young keratinocytes.
- Defensin stimulates LGR6+ stem cells.
- The defensin/LGR6+ pathway plays a role in keratinization.
- Using topical defensin can improve the skin’s appearance.
Studying DefenAge
At this time, there is only one small multicenter, double-blind, placebo-controlled clinical study completed at three locations by investigators who are stockholders in the company and an independent dermatologic histopathologist who has no relation with the company; results have been reported in aesthetic dermatology industry newsletters. Each site had 15 patients for a total of 45 patients; all were women, aged 41-70 years (average age, 60 years), with little or no history of “quality” skin care. The study regimen used a system that contained alpha- and beta-defensins developed by Progenitor Biologics. Thirty patients used the three products in the DefenAge line: the 2-Minute Reveal Masque Exfoliator, 24/7 Barrier Balance Cream, and 8-in-1 BioSerum. The remaining patients received a three-part placebo system. Baseline biopsies were obtained to evaluate underlying conditions in the patients’ skin, and their skin was evaluated at 6 and 12 weeks, when additional biopsies were taken. Data analysis indicated that patients using DefenAge experienced significant improvement in coarse and fine wrinkles, pigmentation, pore prominence, epidermal thickness, as well as skin texture and evenness.
My personal opinion
I have never been a fan of formulations containing stem cells or peptides for the reasons listed above. DefenAge is unique in the way it has been stabilized, by penetrating the hair follicle rather than through the dermis and because defensin has very well-documented effects on the important LGR6+ stem cells. The effects of defensin on LGR6+ stem cells intrigue me. I do not intend to stop recommending retinoids for antiaging, but rather will add DefenAge to the antiaging regimen. In the past year, I have used DefenAge on many patients and have had many observations. I do not recommend starting retinoids and DefenAge at the same time because I have seen increased retinoid dermatitis. I suggest starting one the first month and then introducing the other product during the second month. Although no studies have been performed on this, my impression is that the DefenAge gives a quick result that helps improve patient compliance with the entire skin care regimen, but the effects reach a point at which no further improvement is seen. Combining DefenAge with a skin care regimen (targeted specifically to their Baumann Skin Type of course!) that includes a retinoid will increase efficacy. For wrinkle-prone skin types, I combine DefenAge with a retinoid, vitamin C, and heparan sulfate. After cleansing in the morning, I have them apply vitamin C followed by the DefenAge and an SPF. In the evening after cleansing, I have them apply a retinoid followed by a heparan sulfate analogue.
Conclusion
DefenAge offers a new approach to skin aging. At this time, there is much basic science research about the benefits of LGR6+ and that uses defensin to stimulate these stem cells; however, only one small clinical trial using defensin topically for antiaging has been published. It is doubtful that many studies will be performed because cosmetic companies are not allowed to make biologic claims so they have little incentive to demonstrate biologic changes. For this reason, we have to rely upon anecdotal reports from physicians such as the information that I have shared here.
Conflict of interest note: I have no financial relationship (no honorarium, stocks, or research funding) with Progenitor Biologics. I was asked to lecture in a DefenAge Symposium at the Vegas Cosmetic Surgery meeting but received no compensation. DefenAge products are sold through doctors, with my company, Skin Type Solutions Franchise Systems, as are heparan sulfate analogues, multiple brands of retinol, and 40 other product brands.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
2. Snippert HJ et al. Science. 2010 Mar 12;327(5971):1385-9.
3. Lough DM et al. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
4. Kiatsurayanon C et al. J Invest Dermatol. 2014 Aug;134(8):2163-73.
Most skin-aging treatments work by prodding old fibroblasts and keratinocytes to accelerate the production of important cellular components. For example, retinoids act on retinoic acid receptors to activate collagen genes and deactivate collagenase genes. Glycolic acid, ascorbic acid, and certain growth factors stimulate synthesis of collagen by fibroblasts. Older fibroblasts and keratinocytes are sluggish for many reasons; they do not “hear” signals as well as younger cells do. Glycosaminoglycans such as heparan sulfate can help cells hear these signals. Heparan sulfate, for example, assists in the delivery of growth factors to cells, stabilizes them, and presents them to the receptors on the keratinocytes and fibroblasts, and amplifies cellular response to these factors.
A new angle in antiaging skin care is to create new keratinocytes rather than to stimulate old cells. For the last decade, personal care companies have touted the benefit of putting stem cells in cosmeceuticals, claiming that these cells would rejuvenate skin. However, this proved to be unsubstantiated marketing hype because the stem cells were plant derived (often from apples), had poor shelf life, and could not intercalate between the native skin cells and work with them to have any effect. Stems cells in cosmeceuticals became a point of disdain for savvy scientists.
Stem cells
Wounding the skin stimulates LGR6+ stem cells. This occurs when neutrophils in the immune system release defensins in response to injury, and, in turn, defensins activate LGR6+ stem cells. Situated above the follicular bulge, these cells are reported to have the capacity to synthesize all cutaneous cell lineages, including sebaceous gland and interfollicular epidermal cells.1,2 There are no specific studies that show that the LGR6+ cells generate new fibroblasts, but it seems likely. Transplantation of LGR6+ stem cells into the skin results in increased wound healing, hair follicle genesis, and angiogenesis.3 LGR6+ stem cells repopulate the epidermis by creating new basal stem cells. In regards to skin rejuvenation, it is clear that activated LGR6+ stems cells produce new, younger-acting keratinocytes in the epidermis.
Peptides
Defensin is a peptide. Peptides are short amino acid chains. These important substances are challenging to incorporate into topical formulations for various reasons, including stabilization difficulty, interaction with other molecules, and poor penetration (greater than 500 Dalton molecular weight). For these reasons, many peptide-containing formulations do not have efficacy. Attempts are underway to better develop or modify peptide products to enhance solubility, achieve better penetration, and target increased receptor activity. Defensins are peptides, which makes them difficult to formulate in a topical product. Special steps must be taken in the formulation process to stabilize defensin and allow penetration into the hair follicle where the LGR6+ cells reside. Fortunately, it is easier for a peptide to target the hair follicle because it can traverse through the “pore” – than it is to get a peptide to reach the fibroblasts in the dermis.
Defensins
Defensins, or human beta-defensins, are host defense peptides that exhibit antimicrobial activities against numerous bacteria.4 LGR6+ stem cells, which are dormant until they are activated to respond to damage, are stimulated by defensins. Defensins have been shown to stimulate keratinocyte proliferation, migration, and wound healing. (3) **Human alpha-defensin 5 peptide has also been shown to enhance wound healing, increasing LGR5+ and LGR6+ stem cell migration in the wound bed.(1)***
When formulated in a manner that allows for stability and penetration into the hair follicle where the LGR6+ stem cells reside, defensin formulations can be applied topically. A product sold as DefenAge uses a patented formulation that uses albumin, a large and stable protein, to stabilize defensin and act as a carrier molecule while helping the defensin maintain its integrity and extend shelf life in the serum base. The albumin/defensin complex is incorporated into liposomes to prevent other ingredients in the cosmetic base from interacting with the peptide and to enhance delivery to the LGR6+ target cell.
The role of defensins in treating skin aging
- Old fibroblast and keratinocytes are sluggish and lazy.
- Old cells do not “hear” signals as well as younger cells.
- LGR6+ stem cells repopulate the epidermis with new, young keratinocytes.
- Defensin stimulates LGR6+ stem cells.
- The defensin/LGR6+ pathway plays a role in keratinization.
- Using topical defensin can improve the skin’s appearance.
Studying DefenAge
At this time, there is only one small multicenter, double-blind, placebo-controlled clinical study completed at three locations by investigators who are stockholders in the company and an independent dermatologic histopathologist who has no relation with the company; results have been reported in aesthetic dermatology industry newsletters. Each site had 15 patients for a total of 45 patients; all were women, aged 41-70 years (average age, 60 years), with little or no history of “quality” skin care. The study regimen used a system that contained alpha- and beta-defensins developed by Progenitor Biologics. Thirty patients used the three products in the DefenAge line: the 2-Minute Reveal Masque Exfoliator, 24/7 Barrier Balance Cream, and 8-in-1 BioSerum. The remaining patients received a three-part placebo system. Baseline biopsies were obtained to evaluate underlying conditions in the patients’ skin, and their skin was evaluated at 6 and 12 weeks, when additional biopsies were taken. Data analysis indicated that patients using DefenAge experienced significant improvement in coarse and fine wrinkles, pigmentation, pore prominence, epidermal thickness, as well as skin texture and evenness.
My personal opinion
I have never been a fan of formulations containing stem cells or peptides for the reasons listed above. DefenAge is unique in the way it has been stabilized, by penetrating the hair follicle rather than through the dermis and because defensin has very well-documented effects on the important LGR6+ stem cells. The effects of defensin on LGR6+ stem cells intrigue me. I do not intend to stop recommending retinoids for antiaging, but rather will add DefenAge to the antiaging regimen. In the past year, I have used DefenAge on many patients and have had many observations. I do not recommend starting retinoids and DefenAge at the same time because I have seen increased retinoid dermatitis. I suggest starting one the first month and then introducing the other product during the second month. Although no studies have been performed on this, my impression is that the DefenAge gives a quick result that helps improve patient compliance with the entire skin care regimen, but the effects reach a point at which no further improvement is seen. Combining DefenAge with a skin care regimen (targeted specifically to their Baumann Skin Type of course!) that includes a retinoid will increase efficacy. For wrinkle-prone skin types, I combine DefenAge with a retinoid, vitamin C, and heparan sulfate. After cleansing in the morning, I have them apply vitamin C followed by the DefenAge and an SPF. In the evening after cleansing, I have them apply a retinoid followed by a heparan sulfate analogue.
Conclusion
DefenAge offers a new approach to skin aging. At this time, there is much basic science research about the benefits of LGR6+ and that uses defensin to stimulate these stem cells; however, only one small clinical trial using defensin topically for antiaging has been published. It is doubtful that many studies will be performed because cosmetic companies are not allowed to make biologic claims so they have little incentive to demonstrate biologic changes. For this reason, we have to rely upon anecdotal reports from physicians such as the information that I have shared here.
Conflict of interest note: I have no financial relationship (no honorarium, stocks, or research funding) with Progenitor Biologics. I was asked to lecture in a DefenAge Symposium at the Vegas Cosmetic Surgery meeting but received no compensation. DefenAge products are sold through doctors, with my company, Skin Type Solutions Franchise Systems, as are heparan sulfate analogues, multiple brands of retinol, and 40 other product brands.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
2. Snippert HJ et al. Science. 2010 Mar 12;327(5971):1385-9.
3. Lough DM et al. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
4. Kiatsurayanon C et al. J Invest Dermatol. 2014 Aug;134(8):2163-73.
Most skin-aging treatments work by prodding old fibroblasts and keratinocytes to accelerate the production of important cellular components. For example, retinoids act on retinoic acid receptors to activate collagen genes and deactivate collagenase genes. Glycolic acid, ascorbic acid, and certain growth factors stimulate synthesis of collagen by fibroblasts. Older fibroblasts and keratinocytes are sluggish for many reasons; they do not “hear” signals as well as younger cells do. Glycosaminoglycans such as heparan sulfate can help cells hear these signals. Heparan sulfate, for example, assists in the delivery of growth factors to cells, stabilizes them, and presents them to the receptors on the keratinocytes and fibroblasts, and amplifies cellular response to these factors.
A new angle in antiaging skin care is to create new keratinocytes rather than to stimulate old cells. For the last decade, personal care companies have touted the benefit of putting stem cells in cosmeceuticals, claiming that these cells would rejuvenate skin. However, this proved to be unsubstantiated marketing hype because the stem cells were plant derived (often from apples), had poor shelf life, and could not intercalate between the native skin cells and work with them to have any effect. Stems cells in cosmeceuticals became a point of disdain for savvy scientists.
Stem cells
Wounding the skin stimulates LGR6+ stem cells. This occurs when neutrophils in the immune system release defensins in response to injury, and, in turn, defensins activate LGR6+ stem cells. Situated above the follicular bulge, these cells are reported to have the capacity to synthesize all cutaneous cell lineages, including sebaceous gland and interfollicular epidermal cells.1,2 There are no specific studies that show that the LGR6+ cells generate new fibroblasts, but it seems likely. Transplantation of LGR6+ stem cells into the skin results in increased wound healing, hair follicle genesis, and angiogenesis.3 LGR6+ stem cells repopulate the epidermis by creating new basal stem cells. In regards to skin rejuvenation, it is clear that activated LGR6+ stems cells produce new, younger-acting keratinocytes in the epidermis.
Peptides
Defensin is a peptide. Peptides are short amino acid chains. These important substances are challenging to incorporate into topical formulations for various reasons, including stabilization difficulty, interaction with other molecules, and poor penetration (greater than 500 Dalton molecular weight). For these reasons, many peptide-containing formulations do not have efficacy. Attempts are underway to better develop or modify peptide products to enhance solubility, achieve better penetration, and target increased receptor activity. Defensins are peptides, which makes them difficult to formulate in a topical product. Special steps must be taken in the formulation process to stabilize defensin and allow penetration into the hair follicle where the LGR6+ cells reside. Fortunately, it is easier for a peptide to target the hair follicle because it can traverse through the “pore” – than it is to get a peptide to reach the fibroblasts in the dermis.
Defensins
Defensins, or human beta-defensins, are host defense peptides that exhibit antimicrobial activities against numerous bacteria.4 LGR6+ stem cells, which are dormant until they are activated to respond to damage, are stimulated by defensins. Defensins have been shown to stimulate keratinocyte proliferation, migration, and wound healing. (3) **Human alpha-defensin 5 peptide has also been shown to enhance wound healing, increasing LGR5+ and LGR6+ stem cell migration in the wound bed.(1)***
When formulated in a manner that allows for stability and penetration into the hair follicle where the LGR6+ stem cells reside, defensin formulations can be applied topically. A product sold as DefenAge uses a patented formulation that uses albumin, a large and stable protein, to stabilize defensin and act as a carrier molecule while helping the defensin maintain its integrity and extend shelf life in the serum base. The albumin/defensin complex is incorporated into liposomes to prevent other ingredients in the cosmetic base from interacting with the peptide and to enhance delivery to the LGR6+ target cell.
The role of defensins in treating skin aging
- Old fibroblast and keratinocytes are sluggish and lazy.
- Old cells do not “hear” signals as well as younger cells.
- LGR6+ stem cells repopulate the epidermis with new, young keratinocytes.
- Defensin stimulates LGR6+ stem cells.
- The defensin/LGR6+ pathway plays a role in keratinization.
- Using topical defensin can improve the skin’s appearance.
Studying DefenAge
At this time, there is only one small multicenter, double-blind, placebo-controlled clinical study completed at three locations by investigators who are stockholders in the company and an independent dermatologic histopathologist who has no relation with the company; results have been reported in aesthetic dermatology industry newsletters. Each site had 15 patients for a total of 45 patients; all were women, aged 41-70 years (average age, 60 years), with little or no history of “quality” skin care. The study regimen used a system that contained alpha- and beta-defensins developed by Progenitor Biologics. Thirty patients used the three products in the DefenAge line: the 2-Minute Reveal Masque Exfoliator, 24/7 Barrier Balance Cream, and 8-in-1 BioSerum. The remaining patients received a three-part placebo system. Baseline biopsies were obtained to evaluate underlying conditions in the patients’ skin, and their skin was evaluated at 6 and 12 weeks, when additional biopsies were taken. Data analysis indicated that patients using DefenAge experienced significant improvement in coarse and fine wrinkles, pigmentation, pore prominence, epidermal thickness, as well as skin texture and evenness.
My personal opinion
I have never been a fan of formulations containing stem cells or peptides for the reasons listed above. DefenAge is unique in the way it has been stabilized, by penetrating the hair follicle rather than through the dermis and because defensin has very well-documented effects on the important LGR6+ stem cells. The effects of defensin on LGR6+ stem cells intrigue me. I do not intend to stop recommending retinoids for antiaging, but rather will add DefenAge to the antiaging regimen. In the past year, I have used DefenAge on many patients and have had many observations. I do not recommend starting retinoids and DefenAge at the same time because I have seen increased retinoid dermatitis. I suggest starting one the first month and then introducing the other product during the second month. Although no studies have been performed on this, my impression is that the DefenAge gives a quick result that helps improve patient compliance with the entire skin care regimen, but the effects reach a point at which no further improvement is seen. Combining DefenAge with a skin care regimen (targeted specifically to their Baumann Skin Type of course!) that includes a retinoid will increase efficacy. For wrinkle-prone skin types, I combine DefenAge with a retinoid, vitamin C, and heparan sulfate. After cleansing in the morning, I have them apply vitamin C followed by the DefenAge and an SPF. In the evening after cleansing, I have them apply a retinoid followed by a heparan sulfate analogue.
Conclusion
DefenAge offers a new approach to skin aging. At this time, there is much basic science research about the benefits of LGR6+ and that uses defensin to stimulate these stem cells; however, only one small clinical trial using defensin topically for antiaging has been published. It is doubtful that many studies will be performed because cosmetic companies are not allowed to make biologic claims so they have little incentive to demonstrate biologic changes. For this reason, we have to rely upon anecdotal reports from physicians such as the information that I have shared here.
Conflict of interest note: I have no financial relationship (no honorarium, stocks, or research funding) with Progenitor Biologics. I was asked to lecture in a DefenAge Symposium at the Vegas Cosmetic Surgery meeting but received no compensation. DefenAge products are sold through doctors, with my company, Skin Type Solutions Franchise Systems, as are heparan sulfate analogues, multiple brands of retinol, and 40 other product brands.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
2. Snippert HJ et al. Science. 2010 Mar 12;327(5971):1385-9.
3. Lough DM et al. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
4. Kiatsurayanon C et al. J Invest Dermatol. 2014 Aug;134(8):2163-73.
Enhancing the effects of microfocused ultrasound with cosmeceuticals
The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.1 Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.
Two weeks before the procedure
Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.15 The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.18 Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.19,20
Postprocedure skin care
Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.24 Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.25
Adverse events
Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.26 Other adverse events, which are transient and rare, may include discomfort and mild bruising.
Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
Conclusion
Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.
2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.
3. Dermatol Surg. 2015 Mar;41(3):327-35.
4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.
5. Dermatol Surg. 2015 Jul;41(7):821-6.
6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.
7. Dermatol Surg. 2012 May;38(5):754-9.
8. Dermatol Surg. 2014 Oct;40(10):1113-7.
9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.
10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]
11. Arch Dermatol. 2004 Feb;140(2):204-9.
12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.
15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
17. J Korean Med Sci. 1996 Aug;11(4):335-41.
18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.
20. Exp Dermatol. 2003;12 Suppl 2:57-63.
21. Dermatol Surg. 2001 Feb;27(2):137-42.
22. Br J Dermatol. 1992 Sep;127(3):247-53.
23. J Invest Dermatol. 1991;96:587.
24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.
25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.
26. Lasers Surg Med. 2018 Jan;50(1):13-9.
The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.1 Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.
Two weeks before the procedure
Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.15 The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.18 Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.19,20
Postprocedure skin care
Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.24 Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.25
Adverse events
Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.26 Other adverse events, which are transient and rare, may include discomfort and mild bruising.
Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
Conclusion
Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.
2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.
3. Dermatol Surg. 2015 Mar;41(3):327-35.
4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.
5. Dermatol Surg. 2015 Jul;41(7):821-6.
6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.
7. Dermatol Surg. 2012 May;38(5):754-9.
8. Dermatol Surg. 2014 Oct;40(10):1113-7.
9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.
10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]
11. Arch Dermatol. 2004 Feb;140(2):204-9.
12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.
15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
17. J Korean Med Sci. 1996 Aug;11(4):335-41.
18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.
20. Exp Dermatol. 2003;12 Suppl 2:57-63.
21. Dermatol Surg. 2001 Feb;27(2):137-42.
22. Br J Dermatol. 1992 Sep;127(3):247-53.
23. J Invest Dermatol. 1991;96:587.
24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.
25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.
26. Lasers Surg Med. 2018 Jan;50(1):13-9.
The use of microfocused ultrasound (MFUS) emerged in dermatology in 2009 as a minimally invasive approach to treating mild to moderate facial and neck laxity. Microfocused ultrasound with visualization (MFU-V), as represented by the device Ultherapy, adds high-resolution ultrasound imaging so that the user can see the targets for MFUS energy. Visualization also allows the user to choose the appropriate treatment depth and transducer.1 Since its introduction, Ultherapy has been investigated for efficacy and safety in tightening, lifting, and wrinkle reduction beyond the face and neck, specifically including the décolletage, abdomen, arms/elbows, knees, medial thighs, and buttocks.1-8 This column will focus on using cosmeceuticals to improve the skin-tightening outcomes of microfocused ultrasound.
Two weeks before the procedure
Ingredients that should be used prior to MFU-V include retinoids, such as tretinoin and retinol. Various studies have demonstrated that pretreatment with tretinoin increases collagen production and speeds wound healing.12-14 Kligman et al. assessed wound healing after punch biopsy and found that arm wounds pretreated with tretinoin cream 0.05%-0.1% were significantly smaller by 35%-37% on days 1 and 4 and by 47%-50% on days 6, 8, and 11 than were wounds on the untreated arms.15 The majority of studies on the subject recommend a 2- to 4-week tretinoin pretreatment regimen because peak epidermal hypertrophy occurs after 7 days of tretinoin application and normalizes after 14 days of continued treatment.16,17 This time frame allows for the skin to recover from any retinoid dermatitis prior to the procedure. Adapalene should be started 5-6 weeks prior to procedures because it has a longer half-life and requires an earlier initiation period.18 Although studies have not been performed evaluating the efficacy of topical ascorbic acid and hydroxy acids, pretreating skin with them also may accelerate collagen production after procedures such as MFU-V.19,20
Postprocedure skin care
Because no incision or ablation occurs with MFUS, the use of ascorbic acid, hydroxy acids, and retinoids can and should be continued after the procedure in addition to before the procedure. The combination of topical Arnica montana and Rhododendron tomentosum in a gel pad has been shown to mitigate postoperative ecchymosis and edema after oculofacial surgery.24 Topical curcumin has been shown to facilitate wound healing in animals, but its smell and color make it difficult to use topically. I recommend adding turmeric to food pre- and postprocedure.25
Adverse events
Late in 2017, Friedmann et al. offered a report on the nature of the rare complications from MFUS, which have included mild and fleeting ecchymosis, edema, erythema, and nerve paralysis. In this retrospective multicenter case series of five patients seen in the authors’ practice who experienced serious adverse reactions to Ultherapy, the authors reported that single sessions of MFUS yielded blistering, erosion/ulceration, or cutaneous or subcutaneous tissue edema with resulting atrophy and/or cutaneous necrosis. The authors concluded that while serious adverse events following MFUS are rare, such reactions might be underreported and should be prepared for with early management to diminish inflammation.26 Other adverse events, which are transient and rare, may include discomfort and mild bruising.
Educating patients on pre- and postprocedure instructions can help minimize adverse events. Avoiding foods that decrease platelet function, like ginger, green tea, alcohol (red wine), salmon, and flax seeds, can reduce the risk of bruising. Use of topical and oral antioxidants before and after treatments also may help reduce inflammation and edema.
Conclusion
Please email me at [email protected] if you have any comments, suggestions, or anecdotal reports to share on using cosmeceuticals and nutraceuticals before and after procedures. I will share your responses on my LinkedIn account.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems.
References
1. Clin Cosmet Investig Dermatol. 2017 Oct 30;10:423-9.
2. J Am Acad Dermatol. 2013 Dec;69(6):965-71.
3. Dermatol Surg. 2015 Mar;41(3):327-35.
4. J Cosmet Dermatol Sci Appl. 2012;2(2A):108-16.
5. Dermatol Surg. 2015 Jul;41(7):821-6.
6. J Cosmet Laser Ther. 2014 Oct;16(5):225-9.
7. Dermatol Surg. 2012 May;38(5):754-9.
8. Dermatol Surg. 2014 Oct;40(10):1113-7.
9. Clin Cosmet Investig Dermatol. 2015; 8: 47-52.
10. Dermatol Surg. 2017 Sep 8. doi: 10.1097/DSS.0000000000001216. [Epub ahead of print]
11. Arch Dermatol. 2004 Feb;140(2):204-9.
12. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
13. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
14. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.
15. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
16. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
17. J Korean Med Sci. 1996 Aug;11(4):335-41.
18. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
19. Proc Natl Acad Sci U S A. 1981 May; 78(5): 2879-82.
20. Exp Dermatol. 2003;12 Suppl 2:57-63.
21. Dermatol Surg. 2001 Feb;27(2):137-42.
22. Br J Dermatol. 1992 Sep;127(3):247-53.
23. J Invest Dermatol. 1991;96:587.
24. Ophthal Plast Reconstr Surg. 2017 Jan/Feb;33(1):47-52.
25. Wound Repair Regen. 1998 Mar-Apr;6(2):167-77.
26. Lasers Surg Med. 2018 Jan;50(1):13-9.
Using oral and topical cosmeceuticals to prevent and treat skin aging, Part II
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
6. Mech Ageing Dev. 1986 Jul;35(2):185-98.
7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
6. Mech Ageing Dev. 1986 Jul;35(2):185-98.
7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
6. Mech Ageing Dev. 1986 Jul;35(2):185-98.
7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
Using oral and topical cosmeceuticals to prevent and treat skin aging, Part I
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
It is important for dermatologists to recognize patients at an increased risk of skin aging early enough to initiate countermeasures. “Wrinkle-prone” skin types can be identified easily through use of the Baumann Skin Type Indicator Questionnaire.1 The wrinkle-prone Baumann skin type is associated with age or with lifestyle factors that increase the risk for promoting skin aging.2 Prevention and treatment of numerous signs of cutaneous aging can be achieved through consistent daily use of oral and topical products suited to the identified specifically wrinkle-prone Baumann skin type.
Skin aging
The numerous causes of skin aging can be divided into two broad categories: intrinsic and extrinsic. Intrinsic aging results from cellular processes that occur over time and is influenced by genetics. Such aging is characterized by decreased function of keratinocytes and fibroblasts, intra- and extracellular accumulation of by-products, reduced function of sirtuins (proteins that regulate cell metabolism and aging), mitochondrial damage, and loss of telomeres.
Extrinsic aging results from environmental exposures that engender cell damage, including UV light, infrared and radiation exposure, air pollution, smoking, tanning beds, alcohol and drug usage, stress, and poor diet. Extrinsic aging occurs as a result of intersecting processes caused by free radicals, DNA damage, glycation, inflammation, and other actions by the immune system. Generally, these factors can be partially mitigated through behavioral change. As much as 80% of facial aging can be ascribed to sun exposure.4 Several mechanisms through which sun exposure promotes aging have been well characterized. DNA damage results when UV light induces covalent bonds between nucleic acid base pairs and forms thymine dimers, which can alter tumor suppressor gene p53 function, thereby increasing the risk of cutaneous cancers and aging.5 UV exposure also yields free radicals that create damaging oxidative stress,6 which can activate the arachidonic acid pathway resulting in inflammation.7 Other skin aging mechanisms are not as well understood.
The cellular role in aging: Keratinocytes and fibroblasts
Keratinocyte cells found in layers that resemble the brick-and-mortar structure of a brick wall compose the epidermis. Each epidermal layer exhibits specific functional roles and characteristics. The top layer of the epidermis, known as the stratum corneum, is notable because it forms the skin barrier. This protective barrier contains cross-linked proteins for strength, antioxidants to protect the cells from free radicals, a bilayer lipid membrane layer to prevent water evaporation from the cells surface, immune cells, antimicrobial peptides, and a natural microbiome. Damage to any layer of the epidermis can unleash a cascade of events that can lead to increased cutaneous aging.
The dermis is composed of fibroblast cells, which synthesize collagen, elastin, hyaluronic acid, heparan sulfate, and other glycosaminoglycans that keep the skin smooth, strong, and healthy. Collagen confers strength, elastin provides elasticity, and the glycosaminoglycans such as hyaluronic acid, heparan sulfate, and dermatan sulfate bind water, impart volume to the skin, and provide support for important cell-to-cell communication.
When keratinocytes and fibroblasts age, they may no longer respond to cellular signals such as growth factors. The primary aim of any antiaging skin care regimen is to protect and rejuvenate these key skin cells.
Cellular damage that contributes to skin aging
The accumulated damage from intrinsic and extrinsic factors yields keratinocytes and fibroblasts that fail to produce important cellular components as well as they did when they were younger. Cellular factors that age cells include nuclear DNA damage, mitochondrial DNA damage, diminished lysosomal function, structural impairment of proteins, and damage to cell membranes. This harm occurs because of the direct effects of UV radiation, pollution, toxins, free radicals (oxidation), glycation, and inflammation.
Preventing and treating DNA damage
DNA damage presents as thymine-thymine dimers, pyrimidine-pyrimidine dimers, impaired telomeres, or other mutations. Broad-spectrum sunscreens and sun avoidance are important steps in preventing DNA damage induced from exposure to UV radiation. Other cosmeceutical agents have been designed to hinder the effects of UV radiation or to foster DNA repair. Besides sunscreen, the key members of the dermatologic armamentarium against DNA damage are various antioxidants. Data have been gathered over the last few decades that support the protective effects of antioxidants such as polypodium leucotomos,ascorbic acid, and green tea. Other antioxidants are associated with less data, but hypothetically should deliver similar benefits.
Polypodium leucotomos (PL), an oral extract derived from ferns, has been demonstrated to display photoprotective effects at an oral dose of 7.5 mg. PL has consistently exhibited antitumor and skin protective effects.8 A 2004 study in humans revealed that two oral doses of PL contributed to a significant reduction in DNA damage after UV exposure,9 and a 2017 study showed that PL protected skin DNA from UVB.10 Although PL has been linked to topical benefits, it is the oral form that is most often used to protect skin.
Ascorbic acid, also known as vitamin C, has been amply demonstrated to confer benefits when given both orally and topically. An acidic environment is necessary for optimal absorption. Topical application of ascorbic acid, along with vitamin E and ferulic acid, has been demonstrated to decrease the formation of thymine dimers.11 Unlike other antioxidants, ascorbic acid also stimulates procollagen genes in fibroblasts to increase collagen synthesis.12
EpiGalloCatechin-3-O-Gallate (also known as EGCG), the primary active constituent of green tea, has been demonstrated to induce IL-12 to increase the production of enzymes that repair UV-induced DNA damage.15 The proven photoprotective effects of topical and oral green tea include reducing UV-induced erythema, decreasing sunburn cell formation, and attenuating DNA damage.16
Preventing and treating mitochondrial DNA damage
UV radiation elicits mitochondrial DNA damage known as the “common deletion.”17 Damaged mitochondria produce harmful free radicals known as reactive oxygen species. Mitochondria damage caused by ROS decreases the mitochondria’s ability to generate ATP energy, which is necessary for DNA repair and other cellular processes.
Free radicals and UV radiation damage mitochondria, as does normal cellular metabolism. The range of damage includes mitochondrial DNA impairment, loss of mitochondrial enzymes, and decreased ATP production. This leads to less energy for DNA repair and other reparative processes. While there is no established way to reduce mitochondrial damage once it has occurred, several research initiatives to achieve this end are underway. Currently, protecting the mitochondria from harm with sunscreens and antioxidants is the best option.
Antioxidants are effective in preventing the damaging effects of free radicals on vulnerable mitochondria. As a component of the mitochondrial respiratory chain and an antioxidant itself, coenzyme Q10 is particularly useful in this role. CoQ10 is available in both oral and topical formulations. Oral forms should be taken only in the morning because of a caffeine-like effect. Topical forms of CoQ10 have a dark yellow color that may be unappealing to patients. Polypodium leucotomos has been shown to lower the number of common deletions found in the mitochondria of irradiated keratinocytes and fibroblasts.18 The oral form is recommended. Another potent antioxidant, curcumin, is being studied for mitochondrial protective properties.19 Its strong yellow color and smell render it better suited for oral use although many companies are trying to develop cosmetically elegant topical formulations.
Scavenging free radicals
Ultraviolet light, pollution, and other insults engender free radical formation. Even sunscreen use has been linked to increased production of free radicals. Free radicals, also known as reactive oxygen species, harm cells in many ways including mitochondrial damage, DNA mutations, glycation, lysosomal damage, and oxidation of important lipids and other cellular components such as proteins. Antioxidants present various beneficial effects including scavenging free radicals, decreasing activation of mitogen-activated protein kinases, chelation of copper required by tyrosinase, and suppression of inflammatory factors, such as nuclear factor (NF)-
In summary, skin aging has many causes. Although they are not all understood, some of the processes have been elucidated. Next month, this column will focus on the prevention and treatment of inflammation and glycation, as well as reversing the effects of aging on skin cells.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014). She also wrote a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Baumann, Leslie S. “Cosmeceuticals and cosmetic ingredients” (New York: McGraw-Hill Education / Medical, 2014).
2. Baumann, Leslie S. The Baumann Skin Typing System in “Textbook of Aging Skin” (New York: Springer-Verlag Berlin Heidelberg, 2017). pp. 1579-94.
3. Storm A et al. J Am Acad Dermatol. 2008 Dec;59(6):975-80.
4. Uitto J. N Engl J Med. 1997 Nov 13;337(20):1463-5.
5. Tornaletti S et al. Science. 1994;263(5152):1436-8.
6. Bickers D et al. J. Investig. Dermatol. 2006;126(12):2565-75.
7. Yaar M et al. Br J Dermatol. 2007 Nov;157(5):874-87.
8. Parrado C et al. Int J Mol Sci. 2016 Jun 29;17(7). pii: E1026.
9. Middelkamp-Hup MA et al. J Am Acad Dermatol. 2004 Dec;51(6):910-8.
10. Kohli I et al. J Am Acad Dermatol. 2017 Jul;77(1):33-41.
11. Murray JC et al. J Am Acad Dermatol. 2008;59(3):418-25.
12. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
13. Thompson BC et al. PLoS One. 2015 Feb 6;10(2):e0117491.
14. Surjana D et al. Carcinogenesis. 2013 May;34(5):1144-9.
15. Meeran SM et al. Cancer Res. 2006 May 15;66(10):5512-20.
16. Elmets CA et al. J Am Acad Dermatol. 2001 Mar;44(3):425-32.
17. Berneburg M et al. J Invest Dermatol. 2004 May;122(5):1277-83.
18. Villa A et al. J Am Acad Dermatol. 2010 Mar;62(3):511-3.
19. Trujillo J et al. Arch Pharm Chem Life Sci. 2014. doi: 10.1002/ardp.2014002662014.
20. Muthusam V et al. Arch Dermatol Res. 2010 Jan;302(1):5-17.
Recommending efficacious cleansers for your patients
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates
Reference
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates
Reference
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates