U.S. consumer demand for skincare products continues to grow, and aesthetic practices nationwide are looking for ways to position themselves as skincare experts by recommending products and counseling patients. Practices are using cosmeceuticals to optimize outcomes, and some are becoming product retailers.
“Skincare and cosmeceuticals are a field that is constantly expanding and is one of the fastest growing fields in personal care products. In North America, the cosmeceutical products market is forecasted to reach $18 billion by 2025. This is an area where I see constant growth in my practice,” said board-certified dermatologist Rawaa Almukhtar, MD, of Henry Ford Health in Detroit, Mich., who is referring to statistics by the market research company Mordor Intelligence.
The cosmeceuticals market, which includes skincare, such as anti-aging, sun protection, anti-acne, moisturizers, even hair care and oral care, is forecasted to grow at a compound annual growth rate (CAGR) of 8.25% from 2016 to 2026, according to Mordor Intelligence.
According to Kim Nichols, MD, a board-certified dermatologist and the founder of NicholsMD of Greenwich, Conn., SkinLab by NicholsMD, and NicholsMD of Fairfield, skincare is an integral aspect of a dermatology practice, “…whether through a customized regimen or an individualized treatment plan. With skincare products, each initial consultation includes a suggested regimen based on patient’s skin type and concerns. I teach my staff to educate patients on the importance of at-home skincare as well. Half of the battle with any skin condition is maintaining [the] skin’s health in-between visits to the office,” Dr. Nichols shared.
However, knowing what products come to the surface in a sea of options as offering more than hype can be tricky. It comes down to the science, and not all skincare manufacturers have studies to back their claims.
“Providing advice alongside products that are backed by evidence and clinical studies are important services that we can provide to all our patients,” Dr. Almukhtar stated.
Dr. Almukhtar uses skincare for medical dermatology and cosmetic patients and often combines skincare with prescription treatments. She asserted that all the products she recommends have clinical studies behind them that prove safety and positive outcomes.
In Dr. Nichol’s practice, “Products are applied to every patient prior to them leaving the office, regardless of what treatment they have received.
“For example, antioxidants and UV defense are included in every patient’s regimen, so both products are applied after any treatment in the office. Some products are more suitable for certain treatments. Oftentimes, I will apply a hyaluronic acid-based serum after injectables, whereas lasers require a more nourishing post-procedure moisturizer or restorative face mask,” Dr. Nichols continued.
To successfully incorporate skincare into aesthetic practice, it is crucial to include it in the entire patient experience from start to finish, which means putting products on display throughout the office and allowing patients to feel the products on their skin, Dr. Nichols explained.
Some Basics
Not all topicals are created equal. “For example, the size of the molecule is important, and that is something we need to look at or ask the companies about. Molecules that are larger than 500 kilodaltons are unlikely to penetrate the skin,” Dr. Almukhtar warned.
“Another thing to pay attention to is the kinds of active ingredients that penetrate into the skin,” she continued. “Now, there is a move toward newer technology that allows for combining multiple active ingredients. Microencapsulation is a technology that protects multiple active ingredients from interacting with each other and protects the active ingredients from environmentally-induced oxidative damage.”
Dr. Almukhtar shed light on a newer technology, Altreno’s Tretinoin Lotion 0.05%. “We recently published a study in the Journal of Drugs in Dermatology that looks at this newer product, a lotion, that combines tretinoin with hyaluronic acid and glycerin in a micro-capsulation method. What we did was combine a non-ablative laser and a 1927 thulium laser with this tretinoin product. This significantly improved facial photodamage, and it was well-tolerated by patients,”1 Dr. Almukhtar emphasized.
Physicians Taking Charge
Oculoplastic surgeon Christopher Zoumalan, MD (Beverly Hills, Calif.) took it upon himself to create clinically investigated and “properly evaluated” products to enhance skin healing. Today, he not only practices but is also the inventor, founder and CEO of the Skinuva line of products.
“When I was looking around for the best scar cream to provide to my patients after eyelid surgery or any other surgery that I perform, I could not find a product that was backed by clinical data,” Dr. Zoumalan noted. “That is when I started to think outside the box as a physician and scientist. I started to investigate potential ingredients that can help improve scarring and found there were so many of them, but they were not included in scar products.”
As a result, he developed Skinuva Scar Cream, which includes synthetic growth factors, which are powerful when used correctly. Dr. Zoumalan pointed out that a scar treatment product needs to contain the right amount of specific growth factors to target wound healing successfully.
“Studies have shown this product improves the scar’s redness, hyperpigmentation and thickness. I included centella asiatica, aloe vera, selective growth factors, hyaluronic acid, vitamin C and silicone cream. Once I developed this product, my colleagues and I conducted clinical trials, including one that was published in the Aesthetic Surgery Journal. We found that it was nearly two times more effective in improving scars compared to traditional silicone cream,”2 Dr. Zoumalan reported.
Dr. Zoumalan recommends starting use of the cream about two weeks after procedures that can cause wounds and scars. “Two weeks post-surgery is usually when scar contraction starts to occur and applying the cream directly on the incision during this time is ideal for optimal wound healing. In order to get the best results, you can use it twice a day for up to three to six months after surgery,” he expanded.
The product has also been clinically studied to support its safety and efficacy in wound healing after CO2 laser resurfacing, chemical peels and microneedling.
Another physician pioneer in the skincare space is dermatologist Carl Thornfeldt, MD, founder of Epionce (Boise, Idaho). He also believed that skincare products must be backed by the kind of clinical studies that physicians expect to see.
The company’s skincare portfolio includes clinically proven Epionce Luminous Eye Serum + Renewal Eye Cream. This anti-aging eye duo blends brightening botanicals, multiple algae extracts and barrier-repairing lipids to reduce under-eye puffiness, increase visible firmness, diminish dark circles and improve the appearance of fine lines and wrinkles. In a study, 95.7% of panelists experienced highly statistically significant improvement in under-eye puffiness at 14 weeks. The retinol-free duo addresses the unique challenges of the eye area – without irritation – while enhancing hydration, repair and protection from environmental pollutants, including blue light according to Epionce.
Top Practice Categories and Recommendations
The essential topical skincare categories for practices to consider include cleansers, moisturizers, sunscreen and antioxidants, according to Dr. Almukhtar. “These are the general products that I recommend to my patients regardless of whether they are doing a procedure or not,” she shared.
Among the antioxidant products that Dr. Almukhtar recommends are SkinCeuticals C E Ferulic Antioxidant Serum and SkinCeuticals Phloretin CF, containing phloretin, vitamin C (l-ascorbic acid) and ferulic acid. The second of which Dr. Almukhtar is likely to recommend to acne-prone patients because it does not have vitamin E. She also recommends Revision Skincare C+ Correcting Complex and Melatonik by ISDIN, which has melatonin, bakuchiol and vitamin C.
“In addition to those products, for day-today at-home use I recommend some topicals based on certain indications that patients are coming in for – anti-aging, acne, rosacea, melasma – or if they are having a procedure in the office,” Dr. Almukhtar noted.
Combining Procedures and Skincare
Dr. Almukhtar might recommend a product that enhances healing and collagen building for patients that have procedures with ablative or non-ablative lasers, energy-based devices or microneedling. “I incorporate a topical that has growth factors and peptides to boost the patient’s ability to grow collagen during the healing process,” she stated.
Products that have research suggesting they help build collagen include Skin Medica’s TNS Recovery Complex, which features a fibroblast culture derived from neonatal foreskin, which is rich in growth factors, explained Dr. Almukhtar.
“I recommend a product that has TriHex technology (Alastin), a proprietary blend of active ingredients that stimulate collagen and elastin synthesis and stimulate wound healing,” Dr. Almukhtar added. “Another technology that stimulates collagen building is a peptide called defensins, combined with a type of stem cell found in hair follicles called LGR6+ (DefenAge), these stem cells are responsible for producing keratinocytes in the epidermis.”
Dr. Almukhtar tends to use these products after procedures, with some exceptions. “One of the products with TriHex technology has a study that shows if we use the product for three weeks before and after laser resurfacing the procedure results in higher patient satisfaction; this is an effect of the increased collagen and elastin building capacity of the skin,”3 Dr. Almukhtar reported.
Michael H. Gold, MD, medical director of the Gold Skin Care Center and Tennessee Clinical Research Center in Nashville, Tenn., says Alastin’s Regenerating Skin Nectar with TriHex Technology (Carlsbad, Calif.) is the company’s hero product.
“We did a study (now published) looking at microneedling on the neck, and the results showed that when you use [the Regenerating Skin Nectar] compared to [placebo], the healing was much faster. It is a great post-procedure product; whether it is laser or microneedling it works great,”4 Dr. Gold remarked.
Akis Ntonos, FNP-C, founder of Aion Aesthetics in New York City, N.Y., uses AnteAGE MD Serum & Accelerator from AnteAge (Irvine, Calif.) to enhance outcomes from in-office treatments.
AnteAGE MD supplies medical-grade solutions exclusively made for providers to treat the skin with anti-inflammatory growth factors derived from human bone marrow stem cells. According to Mr. Ntonos, the system provides exceptional results at a cellular level. “The aqueous formula contains two growth factors TGF-3 and IGF-1,” he expressed. “The system utilizes 21 clinically proven ingredients to enhance healing and provide anti-inflammatory benefits.
“The AnteAGE Serum & Accelerator are used in practice after various treatments such as neurotoxin or filler injections, but they are for at-home use,” Mr. Ntonos continued. “Patients utilize them morning and night by applying the serum first, followed by the accelerator. I suggest that my patients incorporate them in their daily routine.”
Mr. Ntonos said he specifically loves the Accelerator, “because it utilizes bakuchiol, a natural, non-irritating alternative to retinol. This makes this skincare routine acceptable for all skin types without the need for multiple products.”
EMC Pharma’s (Maryland Heights, Mo.) products feature hypochlorous acid (HOCl), which has been shown to eradicate bacteria, reduce inflammation, reduce pruritus, break down biofilm and increase oxygenation. The company has several products in its skincare portfolio including Levicyn Dermal Spray, Levicyn Spray Gel, Celacyn Scar Gel, Acuicyn Eyelid and Eyelash Cleanser, Epicyn and Sebuderm.
“The Levicyn Dermal Spray is a go-to product for about everything we do in the clinic,” Dr. Gold stated. “Levicyn is hypochlorous that destroys almost every [bacterium], fungus and virus known to man. During procedures, it keeps the areas that we are working with clean. You can even put it around the eyes and mouth without consequence, it is not going to hurt anything. I actually keep a bottle on my desk to spray it after I have been in patient rooms, just to keep things clean.”
Dr. Gold also uses the Celacyn Scar Gel. “It has a special delivery system that works really nicely to help reduce the appearance of scars. For raised, old scars, it works really well,” he highlighted.
Managing Photodamage and More
Today’s sunscreens are providing more than just sun protection, according to Dr. Almukhtar. “We published research in the Journal of Drugs in Dermatology looking at a sunscreen that contains peptides, antioxidants and a proprietary enzyme that repairs DNA damage from the sun. The product is called ISDIN Eryfotona Actinica, and the results from the study showed that after 12 weeks of use on the face, there was an 81% improvement on the Investigator Global Aesthetic Improvement Scale. Specifically, investigators noted improvement in skin radiance, facial aesthetics and evenness of skin tone,”5 Dr. Almukhtar reported.
There is growing evidence to support active ingredients other than hydroquinone for addressing pigmentation concerns.
“I tend to recommend hydroquinone-free products,” Dr. Almukthar stated. “There are a few on the market that are backed by evidence. The most common ingredients are tranexamic acid, kojic acid, niacinamide and cysteamine. Examples of products that are tested and will help with pigmentary issues are Lytera 2.0 by SkinMedica, which has tranexamic acid, resorcinol and niacinamide; Discoloration Defense by SkinCeuticals, which has tranexamic acid, niacinamide and Kojic acid; and Cyspera by Scientis, which includes cysteamine. Dr. Almukthar said she tends to use Lytera 2.0 or Discoloration Defense after a laser procedure targeting pigmentation. “Usually, it can be used immediately after the procedure, and patients can continue the treatment for a few weeks until I see them for follow-up.”
Dr. Zoumalan developed Skinuva Brite out of frustration with hydroquinone.
Skinuva Brite uses specific types of synthetic growth factors, along with other clinically proven ingredients that help improve hyperpigmentation. These include tranexamic acid, niacinamide, arbutin and vitamin C.
“Growth factors are potential messengers that help signal our cells to react and respond,” Dr. Zoumalan began. “When it comes to hyperpigmentation, there are certain growth factors that, when elicited, cause more of a melasma reaction or more of a hyperpigmentation response. You do not want to use those growth factors, rather you would want to use the ones that help regulate and improve hyperpigmentation. One is an epidermal growth factor, which is very well studied.”
“Furthermore, when applied topically, evidence suggests that tranexamic acid is almost equal in efficacy to hydroquinone. Nevertheless, it has to be properly formulated to ensure its stability,” Dr. Zoumalan cautioned. “The percentage you use is also important. We did a head-to-head clinical trial published in the Journal of Cosmetic Science comparing the Skinuva Brite product to hydroquinone 4% and found that our product did better with zero adverse reactions.”
Advances in Skincare “Technology”
Biocell Collagen® CG from Modere (Miami, Fla.) is based on the multi-patented Collagen/HA Matrix® Technology featured in the company’s bestselling product, Liquid BioCell®. This naturally co-existing matrix of hyaluronic acid and collagen peptides is enhanced with a patented Bio-Optimized™ process to help ingredients absorb into the surface layers of skin for maximum benefits.
Hyaluronic acid helps deeply hydrate the skin for a plumper, more youthful appearance. Type II collagen helps improve elasticity and firmness, but in their natural state, collagen molecules are too large to be effectively absorbed by the body. The Bio-Optimized manufacturing process achieves the ideal molecular weight – even beyond what typical hydrolyzed collagen can offer.
EXOVEX from Exocel Bio (Doylestown, Pa.) is another example of technology advancing skincare.
EXOVEX uses a proprietary incubation medium and a stringent process to produce high potency and safe exosomes. It is a companion product for skin and hair rejuvenation, used post-microneedling or with energy-based aesthetic applications. The non-lyophilized, live exosomes with growth factors, and miRNA in the product help reduce the signs of aging, according to Exocel Bio.
Glynis Ablon, MD, associate clinical professor at UCLA and founder of the Ablon Skin Institute & Research Center in Manhattan Beach, Calif., typically uses EXOVEX with microneedling and fractionated lasers, “but I just started applying it with dermo electroporation or needleless applications,” she shared. “My patients quickly notice after a few days how their skin is glowing while looking smoother and softer.”
Skincare or Cosmetic Procedure?
RegenPRP + ATS is an example of how skincare and aesthetic procedures meet in the middle. The RegenKit, patented gel-based separation technology, from RegenLab (Brooklyn, N.Y.), is the secret behind this medical device’s ability to provide the standardized preparation qualified as RegenPRP. The precision of the proprietary neutral thixotropic polymer in isolating blood components allows for a solution with a constant acellular profile, explained a RegenLab representative.
“Everyone knows about platelet-rich plasma (PRP), but ATS stands for Autologous Thrombin Serum. This serum is collected from the patient using RegenLab devices. The same applies to the collection of the PRP, which is done simultaneously,” said Sandrine Grept-Locher, MD, an aesthetic medicine specialist at SGL Esthethique in Geneva, Switzerland.
“When I mix the standard PRP with the ATS, the coagulation cascade is activated, transforming the standard PRP into a solid gel that will serve as a matrix for the release of growth and chemotactic factors at the injection sites. I will then use this gel as a tissue filler and regenerator,” she explained.
Treatment triggers a skin rejuvenation process, smoothing wrinkles and fine lines. It fills in volume loss in certain areas of the face, such as nasolabial folds and dark circles, Dr. Grept-Locher illustrated.
PRX-T33 Derm Perfexion is another such example.
Marketed by Love Beauty Pro & Medical (Woburn, Mass.), this regenerative aesthetic treatment combines the effects of hydrogen peroxide, 33% TCA and kojic acid. It is a no-downtime and no photosensitivity treatment that is safe for all skin types and targets aging skin, texture, laxity, wrinkles and dull skin for complete rejuvenation of the face and body, according to Derm Perfexion.
For Ginger L. Urbaniak, MD, of Urbaniak Plastic Surgery & Medical Spa in Clearwater, Fla., PRX-T33 has been a game-changer for treating skin. “We have seen skin laxity improvement along the jawline, over the cheeks and even repair of stubborn wrinkles,” she noted. “As an injector, I have seen my filler perform better for fine lines and wrinkles because the skin is healthier and firmer.”
On the body, Dr. Urbaniak said the abdomen and arms are favorite areas to treat. “We pair this with our medical grade skincare focusing on brightening and tightening,” she shared. “The PRX has kojic acid, so the treatments are a great jumpstart to reverse the signs of sun damage as well.”
Consider Passing on These Products
Dr. Almukhtar does not recommend toners because many are astringents, which can contain high levels of alcohol. “Toner can compromise the skin barrier, and there is no added benefit of adding a toner into a regimen if the patient is already on a good cleanser.
“Another ingredient that I try to get patients away from would be essential oils,” Dr. Almukhtar continued. “These are products that can have multiple ingredients in them that are sensitizing to the skin, and I often see either allergic or irritant contact dermatitis from such products.”
One other product that might be more troublesome than beneficial is coconut oil on an acne-prone patient. “While coconut oil might help a patient with eczema, it can cause breakouts on those who get acne,” stated Dr. Almukhtar.
Expect More from Skincare’s Future
Advances in how skincare is formulated will likely continue to improve penetration of active ingredients and reduce irritation, according to Dr. Almukhtar.
“I think more clinical studies will happen on different skin types and various ethnic backgrounds that would help individualize those in the future,” she speculated.
References:
1. Almukhtar, R., Carr, E., Angra, K., Lipp, M., Boen, M., & Goldman,
M. (-1, November 30). Single-center, prospective, double-blind, evaluator-blind, non-randomized, vehicle-controlled trial with a 1927 nm non-ablative fractionated laser and topical 0.05% tretinoin lotion for facial dyspigmentation and Photodamage
-JDDonline - Journal of Drugs in dermatology. JDDonline. Retrieved July 27, 2022, from https://jddonline.com/articles/
single-center-prospective-double-blind-evaluator-blind-nonrandomized-vehicle-controlled-trial-with-S1545961621P1174X/
2. Zoumalan CI, Tadayon SC, Roostaeian J, Rossi AM, Gabriel
A. Safety and Efficacy of a Scar Cream Consisting of Highly Selective Growth Factors Within a Silicone Cream Matrix: A Double-Blinded, Randomized, Multicenter Study. Aesthet Surg J. 2019 Feb 15;39(3):319-330. doi: 10.1093/asj/sjy185. PMID: 30084900.
3. Vanaman Wilson, MJ, Bolton, J, Fabi, SG. A randomized, single-blinded trial of a tripeptide/hexapeptide healing regimen following laser resurfacing of the face. J Cosmet Dermatol. 2017; 16: 217– 222. https://doi.org/10.1111/jocd.12339
4. Gold, MH, Sensing, W, Biron, JA. A topical regimen improves skin healing and aesthetic outcomes when combined with a radiofrequency microneedling procedure. J Cosmet Dermatol. 2019; 18: 1280– 1289. https://doi.org/10.1111/jocd.13037
5. Kern, J. A., Wood, E., Almukhtar, R., Angra, K., Lipp, M., & Goldman, M. (-1, November 30). Evaluation of an SPF50 sunscreen containing photolyase and antioxidants for its anti-photoaging properties and photoprotection - jddonline-journal of drugs in dermatology. JDDonline. Retrieved July 27, 2022, from https://jddonline.com/articles/evaluation-ofan-spf50-sunscreen-containing-photolyase-and-antioxidantsfor-its-anti-photoaging-prop-S1545961622P0517X/
6. Kalasho BD, Minokadeh A, Zhang-Nunes S, Zoumalan RA, Shemirani NL, Waldman AR, Pletzer V, Zoumalan CI. Evaluating the Safety and Efficacy of a Topical Formulation Containing Epidermal Growth Factor, Tranexamic Acid, Vitamin C, Arbutin, Niacinamide and Other Ingredients as Hydroquinone 4% Alternatives to Improve Hyperpigmentation: A Prospective, Randomized, Controlled Split Face Study. J Cosmet Sci. 2020 Sep/Oct;71(5):263-290. PMID: 33022197.
