The concept of product dispensing is not new in dermatology, but many of the formulations and some of the ingredients available for sale certainly are. Despite the remarkable success experienced by some dispensing practices, some dermatologists remain uncertain how to begin a dispensing initiative or take theirs to another level. There is also some confusion about the true benefits of the various formulations available. The route to success can differ for each practice, but there are elements common to all successful dispensing programs: a well-founded approach to dispensing and the provision of quality products. Speaking at the Cosmetic Surgery Forum in Las Vegas in December, several leading cosmetic dermatologists highlighted keys to success in dispensing and offered insights on products worth considering.

Benefits and Drawbacks
The demand for skin care is significant, Vivian W. Bucay, MD, noted, and patients, “rely on dermatologists, plastic surgeons, and cosmetic physicians to recommend the best products for their specific concerns in caring for their skin, hair and nails.” Cosmeceuticals and other physician-dispensed skincare products may clearly be a part of those recommendations.

Dr. Bucay highlighted multiple benefits associated with offering cosmeceuticals in the practice. Perhaps of greatest clinical significance, by making skincare recommendations and providing specific products in the office, the physician can control or at least monitor what the patient is using on her/his skin. This can be especially helpful before and after procedures, when patients must avoid certain irritating products.

Dermatologists are well qualified to make skincare recommendations to patients, Dr. Bucay said, because they have access to clinical studies and formulation information as well as the medical background needed to understand these products. On their own, consumers do not have similar access to data, and few have sufficient background knowledge to identify the best products.

Of course, cosmeceutical dispensing provides income directly to the practice. There may also be indirect financial benefits for the practice, as cosmeceutical purchases often serve as an entry point to other services and procedures offered in the practice. When implemented properly, Dr. Bucay said, a dispensing program will “boost the bottom line” of a practice while increasing the level of service provided to patients.

There can be downsides associated with cosmeceutical dispensing, Dr. Bucay acknowledged. The greatest challenge can be projecting which products or types of products will work best in your practice and be of greatest interest to patients.

Many practices also find it difficult to effectively track inventory. Inventory tracking is essential for several reasons. For one, it allows the practice to monitor top sellers, which can help guide future decisions about product additions and deletions. Having adequate inventory on hand is important to avoid missed sales opportunities and to ensure that the dispensing program is truly a convenience to patients. Individuals frustrated by a consistent lack of product availability may start buying elsewhere. Finally, inventory tracking helps to avoid “shrinkage,” or loss of product to “borrowing,” theft, or simple misplacement/mismanagement of stock.

Tips for Success
A cornerstone of dispensing success is offering affordable options, Dr. Bucay said. Ira Berman, MD echoed that notion, noting that certain products have been particularly popular in his practice during the recession. This broadens the appeal of dispensing and opens the dispensing program to virtually all patients. Additional product offerings at multiple higher price points then serve to widen the array of products offered.

In addition to using their expertise and access to knowledge to identify effective products, physicians must also evaluate products' safety and tolerability. A product that produces significant irritation, particularly one that causes erythema and/or scaling, will not be acceptable to patients who will in turn be dissatisfied with the physician and practice.

When considering products, be sure that the options you provide are not available from massmarket retailers and department stores, advised Jeanine Downie, MD. Physician dispensed lines must be distinct from these widely-available products. Unfortunately, some lines designed for physician dispensing as well as some high-quality competitive lines are available on-line. Physicians who dispense in the office must be competitive with Internet pricing, Dr. Bucay said. This may require a bit of on-line research.

Educating staff about the benefits of various office-dispensed products and practice policies regarding dispensing, is essential, Dr. Bucay noted. Staff, who often field questions about skincare from patients, should be able to speak knowledgeably about products and should always reinforce and not contradict the physician's advice.

The practice must devise a strategy for dealing with product dissatisfaction, Dr. Bucay advised. That means having policies in place for refunds and exchanges in appropriate instances.

Don't overlook sales tax, Dr. Downie emphasized. Verify local regulations and consult with your own financial and tax advisors to ensure that you are properly applying, capturing, and submitting sales tax on applicable products dispensed from the practice. Failure to do so could lead to exorbitant fines plus additional charges for unpaid taxes.

Products Worth Considering
The panelists described some of the top products they dispense in their practices and described their benefits. While this list is by no means exhaustive, it may provide some guidance.

Sunblocks
EltaUV Clear SPF 46 (Swiss American). Dr. Bucay noted that this sunscreen offers broad spectrum coverage with the includson of zinc oxide 9% and octinoxate 7.5%. “It's oil-free, very lightweight, and contains niacinamide (vitamin B3), which can be beneficial for acne and photodamage,” she added.

Revision Skincare Intellishade SPF 45.
Broad-spectrum sunscreen with microparticle zinc is tinted with Intellishade technology to provide even coverage, while incorporated peptides are intended to help reduce wrinkles and photodamage. Recommended by Dr. Bucay.

Alyria Sunblock Lotion.
This sunscreen provides broad-spectrum protection. It contains zinc oxide, octyl methoxycinnamate, and Vitamin E. Dr. Downie said it is non-greasy, non-irritating, can be used around the eyes and rubs well into olive/dark skin. All sunscreen formulations must be reapplied every two hours, she noted.

MD Forte Aftercare SPF 30. This broad-spectrum (zinc oxide, octinoxate and octisalate) product features the Skin Cancer Foundation seal of approval on the label. It is oil-free, non-comedogenic, hypoallergenic, and cosmetically elegant, Dr. Downie observed.

Anti-aging and Other Indications
TNS Essential Serum (SkinMedica). This growth factor serum is derived from multiple growth factors. The APS corrective complex contains antioxidants and peptides, along with Vitamin C, Vitamin E, and Amino Acids (proline) to promote production of tissue inhibitor of metalloproteinases. The formulation also includes extract of blackberry—an inhibitor of matrix metalloproteinases to prevent the breakdown of collagen and an antioxidant—as well as alpha-arbutin extract from the Bearberry plant that inhibits tyrosinases and provides a lightening effect. Dr. Downie noted that the serum improves texture and tone and builds collagen with initial results noted in about six weeks.

Vivite Vibrance (Allergan). Dr. Downie highlighted data showing that this formulation has efficacy comparable to hydroquinone 4%: It has been shown to reduce hyperpigmentation 89 percent (vs. 83 percent for hydroquinone). It also reduces fine lines and skin roughness. The formulation contains retinol, soy, licorice, mulberry, and grape extracts to even skin tone, along with antioxidants lycopene, olive extract, superoxide dismutase, Vitamin E, and magnesium. Anti-inflammatory ingredients include green tea and licorice.

Revaleskin Intense Recovery (1.5% coffeeberry, Stiefel). Coffeeberry is a powerful antioxidant. Treated patients have had decreased redness after six weeks, along with reductions in fine lines and wrinkles and improvement in texture, tone, dryness, and overall skin appearance. The product is associated with significantly enhanced barrier function, Dr. Downie noted.

Auriderm Post-Op Clearing Gel (Biopelle).
Featuring Vitamin K oxide, this gel is intended for use after sclerotherapy to help eliminate spider veins and clear or reduce post-procedure bruising. It may also be used before sclerotherapy to enhance results. Dr. Bucay recommended the gel, which is intended for twice-daily application.

Cleansing
Trixera Emollient Bath (Avene).
This oil-based, hypoallergenic, and paraben-free bath oil contains Avene thermal spring water, ceramides, sterols, glycerin, essential fatty acids, coconut oil, and castor oil to restore the hydrolipidic barrier and protect skin from moisture loss. It is hydrating, nonsticky, and easily absorbed, according to Dr. Downie. She recommends it for atopic dermatitis, psoriasis, ichthyosis, xerosis and lichen simplex chronicus.

Glycolix Gly/Sal 10/2 Pads (Topix). For acneprone or oily skin, these cleansing pads are effective and convenient, Dr. Bucay said.

Vivite Exfoliating Cleanser (Allergan). Contain-ing glycolic acid and salicylic acid along with gentle exfoliating microbeads, this product features a botanical blend of Vitamin C, olive leaf extract, and pomegranate. It generally improves tone and texture and is also useful for KP, elbows, knees, and heels, according to Dr. Downie.

TNS Illuminating Eye (SkinMedica). Growth factor extract, Vitamin C, dimethicone, hyaluronic acid, and glycerin build collagen, thereby decreasing fine lines and wrinkles. The product slightly decreases dark circles, Dr. Downie said, and is very tolerable and non-irritating.

Replenix CF Cream with Caffeine (Topix).
Dr. Bucay recommended this formulation containing concentrated green tea polyphenols (90 percent polyphenol isolates) and caffeine for anti-aging and anti-inflammatory effects. The emollient cream formulation has a soy phospholipid and hyaluronic acid base. It may be suitable for rosacea, acne, or post-procedure.

Elastiderm Eye Cream (Obagi). Designed to target elastin fibers and improve elasticity of the eyelids, the cream is extremely well tolerated by patients and formulated for use on both upper and lower eyelids, Dr. Bucay said. She noted good clinical studies and photographs documenting the “lift” in upper eyelids at 12 weeks, in addition to improvement in periorbital lines.

Lower Cost/Broad Appeal
CeraVe Cream (Coria Laboratories). Featuring multivesicular emulsion delivery technology to provide a controlled release of ceramides, moisturizers (including hyaluronic acid), and emollients (glycerin, dimethicone), this product is one exception to the mass-market avoidance rule, according to Dr. Berman. It is useful in dry skin and atopic dermatitis and by supporting proper barrier function may help increase the efficacy of other topical products.

Biafine Topical Emulsion (OrthoDermatologics). This relatively low-cost wound-healing formulation is particularly useful to speed wound healing and hasten recovery after procedures, Dr. Berman says. It recruits macrophages to the wound site to remove necrotic debris and stimulate fibroblast proliferation. Fibroblasts promote epithelial cell multiplication. The agent is occlusive and hydrating.

Colorescience All Mineral Make-up. Adding make-up to the list of dispensing menu may be a good expansion of products, Dr. Berman suggests. The Colorescience line is free of dyes, talcs, fillers, mineral oil, or perfume. Iron oxides serves as the base; Bismuth/Oxychloride improves consistency, provides oil control, and is anti-inflammatory. Mica is a binder that provides shine control. Pigmented titanium dioxide provides opacity. Reduced cost refills are available, as is a sunblock line.

Adapted from presentations given at Cosmetic Surgery Forum 2009: cosmeticsurgeryforum.com