Make the Most of Cosmeceutical Agents in Your Practice

Experts weigh in on the science of cosmeceuticals and provide recommendations on specific agents.

By Joel Schlessinger, MD

Cosmeceutical agents play an important role in the dermatology clinic. Whether your practice is more oriented toward medical or cosmetic dermatology, the addition of cosmeceutical agents can only broaden the options for patients. Additionally, it offers a way to provide a ‘one-stop shop’ for your patients, many of whom will appreciate the convenience of purchasing the products you recommend in-house rather than attempting to find suitable options at a local store.

The scientific validity of cosmeceuticals is being shown more each year, with ingredients added which are on the cutting edge of dermatology and which provide a niche in the treatment and cosmetic beautification areas, as well. While FDA rules put cosmeceuticals in somewhat of a “never-never land,” the public and medical communities understand the benefits and opportunities that these products pose for a practice and its patients.

The uses for cosmeceutical agents include the obvious (such as cleansing systems) and the innovative, such as eyelash growth treatments and skin peel devices and systems! There has been a huge change since 10 years ago, when mainly cleansing systems were offered. Additionally, the science behind these available products and ingredients has been clarified, leaving the newer compositions superior to alternative store-bought products.

At the 2011 Cosmetic Surgery Forum, several panelists and attendees weighed in on the state of cosmeceuticals in dermatology and shared their own personal top choices. Recounting the commentary from the panel, this article explores unique benefits of cosmeceutical agents and the overall importance of skin care. In addition, it highlights the panelists’ recommendations for cosmeceutical uses in a variety of conditions.

THE ROLE OF COSMECEUTICALS

The use and popularity of cosmeceutical agents is on the rise in the US. Revenue generated from sales of cosmeceuticals increases each year, totaling more than $7 billion in 2008, notes Heidi Waldorf, MD. For dermatologists, cosmeceuticals occupy an ambivalent position in the specialty. On the one hand, they are essential in healthy skin care and therefore essential tools for dermatologist. However, unlike most other products and agents in the specialty, Dr. Waldorf observes, cosmeceuticals are not subject to a high standard of regulation and therefore do not have to pass through the FDA’s rigorous approval process. This has resulted in pharmacy aisles being flooded with skin care products that vary tremendously in efficacy, often causing confusion in patients looking for the most reliable skin care regimen, adds Dr. Waldorf. It’s also worth noting that cosmeceuticals often have side effects, as topical products can improve or impede a patient’s procedure results. Importantly, side effects can sometimes be harnessed as an innovative use, as witness the ‘unwanted’ eyelash growth that Latisse harnessed into a multi-million-dollar product.

To clarify the significance of cosmeceuticals, it is important to first outline the basic elements of skincare. Jeannette Graf, MD notes that these include cleansing, renewal and rejuvenation, as well as protection and prevention. All of these are essential to maintaining the moisture barrier. Explains Dr. Graf, the stratum corneum contains ceramides, cholesterol, phospholipids, humectants, microflora, and immuno-protective cells. It provides protection from the environment which contains pollutants, UV, pathogens, and irritants. In skin care, the stratum corneum is especially important, since washing, over-exfoliating, and the use of overly acidic and alkaline products tend to disrupt pH balance.

Skin circadian rhythms split into two essential categories, explains Dr. Graf: Renewal mode and Protective mode. Renewal mode takes place at night, when skin pH is lower and transepidermal water loss and skin microcirculation is increased. By contrast, during the daytime hours of protective mode, skin pH is higher and sebum production is increased. Both Dr. Graf and Dr. Waldorf observe that during the daytime, individuals should be hydrating the skin with antioxidant serums, moisturizing sunscreens, and makeups. At night, the skin should be gently cleansed and exfoliated with agents such as retinoids, targeted treatments and peptide/antiaging serums. Importantly, moisturizing is essential in both day-time and night-time skin care, Dr. Waldorf and Dr. Graf note. Moisturizing helps to maintain and renew the lipid barrier and stratum corneum.

The significance of skin care to our specialty coupled with the evolving regulatory circumstances of cosmeceuticals, according to Dr. Waldorf, means that dermatologists essentially have two main options for incorporating cosmeceuticals into practice. The first is recommending over-thecounter products for patients to purchase at drug stores, department stores, or retailers such as Ulta. The second is to dispense cosmeceuticals from the dermatologist’s office. Dr. Waldorf observes that in-office dispensing, while financially lucrative, must be done ethically.

This may mean that a practice that generally treats older individuals carries mainly moisturizers whereas a practice that specializes in pediatric dermatology carries acne-related products. Whatever the case, it is important to sell what makes sense and what the dermatologist believes in or the product will just stay on the shelf. Worse, if a product is sold that is a poor value or is potentially harmful, this could eventually impact the dermatologist’s reputation.

Dr. Schlessinger’s Tip. The benefits have to be weighed carefully and any product brought into the office needs to be evaluated by the physician, his staff or a trusted advisor. This is the only way to assure that the products will sell and deserve to be sold. It is important to consider whether the staff will be incentivized. My office offers very minimal incentives from time to time, but the general rule of thumb is to encourage an environment wherein the products are so good that they sell themselves and integrate within the framework of the practice.

TOP COSMECEUTICALS

Whether you are recommending products or dispensing them in practice, identifying scientifically sound products for the variety of conditions for which cosmeceuticals can be used can be a daunting task. Ahead, panelists reflect on their personal choices for the top cosmeceutical agents.

Barrier Repair and Exfoliation. For moisture barrier preservation, Avene has three products that are very effective, according to Dr. Graf. The first is Eau Avene TriXera emollient cream (AD), a lipid-loaded emollient body cream based in soothing thermal spring water. Eau Thermale Avene Cleanance soap-free facial cream cleanser is also beneficial, as is Eau Thermale Avene Retrinal+ 0.1. Retinaldehyde is a natural precursor of all-transretinoic acid. This particular formulation is excellent for all skintypes as well as sensitive skin.

Regarding exfoliating systems, two products in particular stand out. The first is Glytone’s Mini-Peel Gel, an at-home peel with 10.8% glycolic acid, and Gly/Sal 10/2 Pads, which are presoaked with 10% glycolic acid and 2% salicylic acid, which is effectively used for acne, keratosis pilaris, and post-inflammatory hyperpigmentation. It is easy to use and a great value, according to Dr. Graf.

Another noteworthy product is Nia24 Intensive Recovery Cream, which is one of Dr. Cumming’s top product choices. Discovered by cancer researchers, Nia24 contains the active ingredient Pro-Niacin, a lipophilic form of nicotinic acid (vitamin B6). Nia24 Intensive Recovery Complex stimulates DNA repair and enhances energy metabolism and cell turnover. Additionally, it promotes the release of leptin, a natural repair hormone, and stimulates a receptor that decreases hyperpigmentation. It contains peptides, vitamins A, C & E, licorice root extract (a skin brightener), ceramides 2 and 3, and other skin hydrators.

Dr. Schlessinger’s Tip. I particularly like the Clinician’s Complex Microdermabrasion Cream, with magnesium oxide crystals. This product is one of the top sellers in my practice and a staff favorite.

Lighteners. Dr. Cummings recommends Elure, a natural enzyme without hydroquinone that directly reduces unwanted pigment. Also, for hydroquinone-based products, Neocutis’ Blanche is the most effective, she says. Its L-leucine inhibits tyrosine transport into melanocytes and melanosomes. It also contains phenylethyl resorcinol (a tyrosinase inhibitor); undecylenoyl phenylalanine, an antagonist of alpha MSH, stimulator of melanin formation; and sodium glycerophosphate, a calcium binder, which is important since calcium is involved in several steps of melanin formation, notes Dr. Cummings.

Dr. Schlessinger’s Tip. I favor either these products or Lumixyl, a non-hydroquinone alternative. The Obagi NuDerm system is my favorite 4% hydroquinone system available and integrates well with Retin-A or alternatives.

Antioxidants and Growth Factors. A number of antioxidant-based products can provide relief and brightening as well. Among these is Revaleskin Intense Recovery Treatment (Stiefel/GSK), which contains 1.5% Coffeeberry extract, grapeseed extract, green tea, vitamin E, and soy. It also protect against sun-induced DNA damage, according to Dr. Cummings. Another potent antioxidant is Phloretin CF (SkinCeuticals), a “superantioxidant combination of vitamin C, phloretin and ferulic acid”. In addition, Phloretin CF protects the skin from UV radiation and neutralizes free radicals. Two other effective antioxidants are SkinMedica’s TNS Essential Serum, which contains peptides, skin brighteners, and seven antioxidants, and Vivite’s Vibrance, which combines 15% glycolic acid and vitamins A, C, and E, with 10 additional antioxidants and skin brighteners. Additionally, Vibrance enhances skin renewal and rejuvenation, and reduces hyperpigmentation.

SkinMedica’s TNS Essential Serum and the Neocutis line of products contain growth factor (animal-derived) that is included in a variety of its products, such as the Lumiere Eye Cream. For plant-derived growth factor products, Dr. Graf recommends the Kinerase systems, which contain Kinetin and Zeatin.

Dr. Schlessinger’s Tip. The newest addition to Kinerase’s line is PTMD (ProTherapy MD), which has 40% more Kinetin and 100% more Zeatin than the previous version of ProTherapy MD. • In a twist, the Tensage line of growth factor products contains snailderived growth factor. This product seems to do well and straddles the fine line between human and plant growth factors. Several panelists recommended it. • Controversy still abounds when it comes to whether human, animal, or plant derived growth factors are best. The panelists also addressed issues surrounding whether these growth factors even reached past the stratum corneum. At present, barring absorption via the hair and sebaceous units, it appears less likely that significant amounts can pass through the skin barrier.

Sun Protection. For daytime antioxidant and sun protection, Dr. Graf and Dr. Schlessinger recommend Elta UV Clear SPF 46, an oil-free, dimethicone-coated micronized zinc oxide containing 9.0% zinc oxide and octinoxate 7.5% (niacinamide). In addition, Glytone’s Antioxidant Serum is recommended as an effective antioxidant and sun protective agent. It contains vitamin C as tetrahexyldecyl ascorbate (THD), as well as vitamin E as delta-tocopheryl glucoside complex. It also contains red tea flavonoids and remains in the skin 40 hours after application. Dr. Graf and Dr. Schlessinger also recommend Mineral Colorscience Bronzing Primer SPF 20 Sunforgettable SPF 50 with retractable brush.

Dr. Schlessinger’s Tip. I am a fan of the Laroche Posay Anthelios 60 Ultra Light Fluid for acne prone individuals. My other favorite sun protection product is Heliocare, a pill derived from a fern in Central America, which enhances sunscreen protection and provides protection when in high sun areas or while swimming.

Specialty Areas/Products. In the realm of non-prescription retinoids, Dr. Cummings favors Avene Retinaldehyde and Avene Diroseal, as well as ROC and Neutrogena retinols. For special areas, she suggests TNS Lip Plump System, TNS Line refine, and Neocutis’ Lumiere. For sunscreens, Dr. Cummings recommends Fallene Cotz, Elta SPR 41 and 30, and Neutrogena Ultrasheer with Helioplex. Other miscellaneous products that Dr. Cummings suggests include CeraVe creams, lotions, cleansers, and PM face cream, and Olay regenerist serum and cream.

In terms of eye creams, Dr. Graf suggests Replenix Power of Three Cream, which is unique for having antioxidant, anti-inflammatory, and anti-irritant properties. It contains green tea polyphenols, resveratrol, and caffeine. Dr. Graf also recommends Glytone Antioxidant Anti-Aging Eye Cream Optimized antioxidant system, a product that contains time-released vitamins C and E, red tea flavanoids, and glycolic acid that enhances penetration.

For post-procedure bruising, Dr. Graf suggests Auriderm Post-Op clearing Gel (Biopelle). It contains vitamin K Oxidase, which resolves hemosidern pigment in bruising.

Dr. Schlessinger’s Tip. For marine-related products, I recommend the Phytomer line, especially for stretch mark treatments.

CONCLUSION

Cosmeceuticals have achieved a place at the table in dermatology over the years. While it is estimated that 30 percent of dermatologists presently incorporate them into their practices, it is likely that this will eventually be in the 50 percent or greater range. Because of this ultimate involvement in dermatology practices, it is important to know the attributes of these products and consider introducing them into a practice over time. This will keep the practice relevant and accessible to today’s consumers and patients.

Dr. Schlessinger is an advisory board/consultant, researcher, or stockholder with Allergan, Stiefel/GSK, Galderma, Obagi, Ortho Pharma (Johnson & Johnson), Quinnova, Shering Plough, Revance. He is also President of lovelyskin.com, which is the sole distributor of the FixMySkin line.

Joel Schlessinger, MD is Founder and Course Director of Cosmetic Surgery Forum.

The 2012 Cosmetic Surgery Forum will be held from Nov. 29 – Dec. 1 at the Venetian/Palazzo in Las Vegas, NV. For more information and to register, visit www.cosmeticsurgeryforum. com.

Cosmetic Surgery Forum: Cosmeceuticals Panelists

Miriam Cummings, MD
Southwest Skin Specialists, Scottsdale, AZ
Jeannette Graf, MD
Assistant Clinical Professor, Mount Sinai School of Medicine, NY
S. Manjula Jegasothy, MD President,
Miami Skin Institute; Associate Clinical Professor,
University of Miami Miller School of Medicine
Heidi A. Waldorf, MD
Waldorf Dermatology & Laser Associates, Nanuet NY;
Director of Laser & Cosmetic Dermatology, Mount Sinai Hosptial, NY

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