A panel presentation about cosmeceuticals was presented at the 2008 Dermatology Update meeting held April 10-12 in Whistler, BC. The panelists included 4 dermatologists: Jeffrey Dover, MD, Charles Lynde, MD, Catherine Zip, MD, and Jason Rivers, MD, who discussed cosmeceuticals and the role they play in adjunct therapy/effective skincare regimes in current dermatology practice.
They began by noting that on a daily basis they are asked by their patients to recommend skin care products. In order to be better prepared to address consumer queries and to convey practical information, medical professionals should gain fundamental knowledge of the active agents and available product variations. The panelists suggested that the healthcare provider’s role can be two-fold: to arm consumers with basic, evidence-based information regarding the science behind various active agents, and to make general recommendations based on a patient’s skin-type and individual medical background. They felt that dermatologists’ combined understanding of the skin, drug compounding, pharmacodynamics, and pharmacokinetics, placed them in a unique position to influence patient behaviours, and that because of this they must adopt a well-rounded, informed, unbiased approach. While the panel members agreed that professional codes of conduct discourage them from endorsing specific products, they said that, in general, patients actively seek their recommendation and they often make suggestions from each class of skin care products. They concurred that the focus of their recommendations should be placed on providing education about how cosmeceuticals can be incorporated into existing skin care regimes.
The term “dermatologist recommended” is often seen on product labels, and likely, the intended message being conveyed is that a panel of experts has assessed the product’s efficacy and validated its claims.* The panelists all agreed that there must be evidence for efficacy, not just the extravagant claims that are frequently made.
Individual consumer needs and preferences can greatly assist in dispensing the proper information and narrowing down the types of products for which they can search. Consumer purchasing behaviours are complex and driven by information that is gleaned from multiple sources, as well as being steered by factors such as product efficacy, packaging, and cosmetic acceptability, i.e., patient adherence can be influenced by the product’s feel, scent, etc. Because some active agents (e.g., retinoids, acne medications, botanicals, etc.) can produce sensitizing reactions, it is essential for patients to be counselled on expected side-effects, as well as mitigating factors.
The widely accepted skin care regime that these dermatologists recommend for photoaging is a morning application of a sunscreen, followed by use of a prescription retinoid in the evening, provided that tolerability to retinoids is not a concern. It is important to note that this basic regimen cannot be generalized across all populations; recommendations must be individualized.
Reproducible, scientific evidence has shown that moisturizers yield both therapeutic and cosmetic benefits. Most act by improving barrier function with lipids and oils (decreasing transepidermal water loss) rather than by introducing moisture into the skin. Humectants, such as urea and lactic acid, have some ability to attract water from the dermis and the external environment. The efficacy of moisturizers is mainly derived from their ability to temporarily seal the epidermis and break the dry skin cycle.
Sunscreens and Vitamin D Deficiency
Recently, there has been a great deal of media coverage and published medical literature regarding vitamin D deficiency. As a result, patients are concerned that the use of sunscreens may put them at risk for vitamin D deficiency, and many are asking their physicians for clarification of this pseudo-controversy. There is very little evidence to support the hypothesis that sunscreens modify vitamin D levels. The general consensus in the scientific community is that sufficient levels of vitamin D can be attained from natural sources, i.e., through diet and moderate sun exposure. As this debate is unlikely to resolve in the near future, the panelists recommend continued regular use of a broad spectrum sunscreen with a minimum sun protection factor (SPF) rating of 30, in combination with daily oral vitamin D supplementation at a dose of 800-1,000 IU/day. Daily calcium supplements that include vitamin D are encouraged for women due to their susceptibility to osteoporosis later in life.
The US FDA is currently modifying its monograph on sunscreens, and new guidelines will be released within the next 2-3 years. The current SPF rating system only measures UVB coverage. The changes include an additional methodology that will determine a sunscreen’s UVA protection factor using a 4-star rating system.
The panelists all agreed that contact sensitivities from cosmetics and cosmeceutical products occur, but incidences remain largely unreported to physicians, especially if reactions are mild. Botanical agents are some of the most potent contact allergens. The misperception is that because these cosmetic additives are naturally or plant derived, they pose little or no risk in causing skin sensitivities. Fragrances are also common sources of contact allergens. The present system of ingredient labelling represents an additional layer of confusion when consumers attempt to identify and avoid certain ingredients. For example, a product can claim to be preservative-free; however, the label may disguise an ingredient as a fragrance, when in actuality, it is a preservative with a scent added.
Initiatives by Industry
All the panelists agreed that the cost of any cosmeceutical product is not necessarily a reflection of its efficacy or quality. Increasingly, there is a noticeable effort on the part of larger cosmeceutical manufacturers to engage in clinical studies.The data generated can frequently be found at medical forums as poster presentations and presented at industry-sponsored educational forums/symposia. These attempts to evoke consumer confidence are a first step in the right direction and may form the basis of more accurate product representations.
Education and Information
Most reputable cosmeceutical companies make the scientific data behind specific formulations readily available. However, the panelists stressed that clinicians should be aware that for many cosmeceuticals, much of the scientific data used to support their claims are based on in vitro studies, and that while human studies are performed, the final formulation of the product has frequently not been tested in humans. There is a wealth of information on the internet, but panellists warned that clinicians should be aware that much of the content is based on conjecture and inference and they need to pay close attention to the source of the information/data that supports the content. The panel mentioned that it is common to find many of the reputable cosmeceutical manufacturers presenting their research at scientific meetings; these occasions are ideal for assessing the quality of the data used to support product claims, and health professionals are encouraged to participate in/attend such opportunities. Feedback from participants suggests that there is a need for more of these sessions on adjunct therapy.
The panelists concluded by agreeing that based on the myriad of informational sources, an inquisitive and discerning approach is required to assess the available data on cosmeceuticals. Health professionals need to actively seek and evaluate the information being shared, i.e., through well designed in vitro and in vivo clinical studies. These educational efforts will hopefully contribute to the accurate dissemination of information by medical professionals and to informed decision-making on the part of consumers.