Over the last two decades, the cosmeceutical market has grown by leaps and bounds. Not only is the number of cosmeceutical manufacturers and products on the rise, but the amount of money spent on skin care has also trended upward significantly. As the science and industry of cosmeceuticals continues to grow, dermatologists now find themselves enjoying more opportunities than ever before to expand their repertoires and bolster their practice income. But aside from how they affect our business, cosmeceuticals are arguably changing the treatment landscape of our field. Skin care agents are now more targeted and tolerable, and also contain higher concentrations of active ingredients. These factors may be contributing to a gradual shift in how we think about and treat the skin.
Given all that has changed in such a short period (and how much is likely still to come), it is incumbent upon dermatologists to consider our responsibilities as we navigate the shifting tides of science and commerce of our specialty.
A Rapidly Changing Landscape
It’s difficult to quantify the extent to which cosmeceuticals have impacted dermatology, but many clinicians no doubt have identified creative and beneficial ways to incorporate these agents into their practice over the years. However, it’s worth noting that the specific role of cosmeceuticals in many therapeutic regimens has remained stagnant, which may speak to how we are defining cosmeceuticals. The term “cosmeceuticals” mainly refers to agents that facilitate skin care, and while skin care is important for overall skin health, it is not a determining factor in managing any one dermatologic condition. This may be subtly changing, though, as we are in the midst of what appears to be a shift in what defines prescription agents and over-thecounter (OTC) products.
Perhaps the most prominent example of this change is the case of the various topical forms of vitamin A, which has been used for more than 40 years in dermatology. It is the primary ingredient in topical tretinoin (Retin-A Micro, Renova, Medicis), a go-to prescription treatment for acne and photodamage for several decades. However, over the last 10 years we have seen a movement toward nonprescription retinols, previously thought to be biologically inactive and unstable in topical formulation. Now, retinol is a main ingredient in a variety of OTC products and has been combined with sunblocks and other bioactive ingredients like antioxidants to boost its clinical efficacy. Many patients prefer the less irritating effects of retinols over prescription retinoids, reflected by the explosion of sales in OTC and MD-dispensed retinol-containing products for acne and anti-aging.
This trend has also branched out into general dermatology. Many newer agents from companies such as Avene, CeraVe, and La Roche-Posay are rich with nutrients and other such ingredients that go beyond basic skin care. They encompass ingredients like ceramides that mimic the skin barrier and are useful as repair agents. As such, these agents can potentially play a supplementary role in sun protection, and inflammatory conditions such as acne, eczema, and even psoriasis. These agents are not likely to displace topical steroid prescription agents but rather play a complementary role in treatment. Nevertheless, these products are actively blurring the lines between what was once a very clear divide between prescription agents and OTC products.
There are a variety of factors that elevate the strength and efficacy of newer generations of cosmeceuticals. Products today are generally more cosmetically elegant and acceptable to patients, while the ingredients tend to penetrate the skin more effectively. Innovations in time-release formulations have enabled some agents to maintain strong results over time as the active ingredient is released gradually. Cutting-edge technology such as incorporating plant stem cell technology into anti-aging skin care as well as sophisticated, stable cocktails of growth factors and cytokines in MD-dispensed lines such as TNS Recovery (Skin Medica) and Neocutis products are taking topical skincare one step further.
The role of cosmeceuticals and nutriceuticals in clinical regimens for general dermatology conditions depends on the specific condition being treated. For acne, if you start a patient with a topical like topical tretinoin or adapalene and benzoyl peroxide gel 0.1%/2.5% (Epiduo, Galderma), you might also consider adding an antioxidant or peptidebased OTC agent to counteract the drying effect associated with these agents. Cosmeceuticals can also ease inflammation or prevent some of the post-inflammatory scarring that many acne patients develop as a sequelae. For patients with atopic dermatitis and rosacea, barrier repair creams can bring additional relief for redness or dry, itchy skin. They can also serve as a supplement to topical steroids and offer “steroid free” days to prevent tachphylaxis when treating atopy or psoriasis.
Often the kind of products physicians recommend will vary based on whether they dispense or are recommending OTC items. That’s because the difference between physician-only cosmeceutical lines and typical OTC lines has historically been very pronounced, with much more refined agents being offered to physicians. That is still the case for the most part, but a blurring of those lines may now be occurring. For example, several years ago, La Roche-Posay products were available only through physicians, but now their products are available in pharmacies nationwide. Whether this will be the start of a new trend will likely depend on several economic factors.
With all the advances in cosmeceutical technology, however, they have a long way to go before being considered truly viable additions to a regimen. Since cosmeceuticals are not subject to the same regulatory review as other pharmaceutical agents, clinical studies on the whole are much less comprehensive and conclusive. Nevertheless, companies that offer the best stability profiles and strong evidence for penetrability and efficacy often have the most reliable agents.
While the rapid and recent developments in cosmeceutical science has rendered the industry in a state of flux, one thing we can glean from these trends is that the utility cosmeceuticals in dermatology has become much more nuanced, both in the market and within our therapeutic regimens.
Cosmeceuticals and the Patient
While questions about where cosmeceuticals fit into the dermatology landscape will occupy us for months and years to come, our most immediate focus should be how the explosion of cosmeceuticals affects patients and our interactions with them. With greater numbers and online availability of skin care products, patients are understandably going to have more questions and concerns about the benefits and uses of these agents. As physicians, we should therefore be prepared to field these questions and perhaps even build in more time to our anticipated appointment durations in order to educate patients.
Whether you dispense in-office or not, patients will require more guidance on the issue. This may add additional layers to our relationships with patients, particularly in terms of understanding how much a patient is willing to invest in skin care. Some will want to spend more, whereas others will be more frugal. It is the clinician’s responsibility to identify these cues from patients and streamline options for them that make sense.
When discussing cosmeceutical options with patients, it also is important not to come across as confusing or pushy. Patients do not want to feel that they are being sold something. Rather, I find it helpful to explain the clinical value of cosmeceuticals in terms that patients understand. A conversation about overall skin health is never a bad thing, no matter if a patient is at your practice for medical or cosmetic reasons. There are many ways of handling this, but connecting the patient’s initial problem to broader skin health is a good foundation. Listening to what bothers them most about their condition—ie, itchiness, blotchiness, etc.—will offer you a sense of their priorities. From there, you can make recommendations.
When recommending cosmeceutical agents, I find it best to give patients options rather than telling them to take a particular product. Patients respond more positively when they feel they are taking an active role and are given choices. But I always take care to explain that some available OTC agents might not be as strong or effective as other options. In the end though, while there are many factors in play, most patients want a product that’s well tolerated and soothing for their skin. Moreover, they expect a physician’s recommendation to always be superior in efficacy.
The right cosmeceutical can be a good addition to a therapeutic or daily skin care regimen, but one of the most important aspects of integrating cosmeceuticals is keeping it simple. Many patients that visit my practice do not want a multi-step process for incorporating cosmeceuticals. It’s our job to simplify regimens as much as possible. Yet, we must always be clear why certain formulations are more beneficial than others. Given the lack of regulations and FDA guidelines for cosmeceuticals, manufacturers can essentially say anything they want about their products. Patients cannot be faulted for not telling the difference between agents. Many products lines have appealing packaging and a lot of media hype but fall short on actual benefits. I find it effective to inform patients about the cosmeceutical market and how it differs from drugs. It makes them more discerning consumers. But it also illustrates to the patient why your guidance is particularly valuable.
Guide to the Revolution
As skin care experts, we should be on the forefront of the skin care revolution. Consulting with and guiding patients on the selection and use of cosmeceutical agents may necessitate spending an extra few minutes with them, but it represents an excellent avenue to meaningfully influence their health.
Dina N. Anderson, MD is a board-certified dermatologist in private practice in New York City and a clinical instructor at Mt. Sinai School of Medicine.