Commentary on: Cosmeceuticals: The Principles and Practice of Skin Rejuvenation of Nonprescription Topical Therapy

Facial rejuvenation has evolved to include much more than surgery, with nonsurgical treatments becoming both an adjunct to surgery and the central focus for many patients. However, the evidence of efficacy for these treatments can vary widely. Injectables, lasers, and energy-based devices are brought to market only after vigorous clinical study to achieve FDA approval. Most of the topical skin therapy, or skincare, has eluded these norms. These “cosmeceuticals,” by definition, are the intersection of a drug and a cosmetic. By design, the industry has enjoyed the nonscientific benchmarks and regulatory environment of a cosmetic while asserting a drug’s biologic activity.¹ Evidence-based use of cosmeceuticals can, therefore, be challenging.

The author of “Cosmeceuticals: The Principles and Practice of Skin Rejuvenation of Nonprescription Topical Therapy” ² attempts to bring scientific rationale to our cosmeceutical skin treatment strategies. The section on the pathophysiology of skin aging and the physiology of skin repair is excellent. These principles should establish the foundation of any treatment strategy. The author’s more challenging goal is to provide a context in which cosmeceuticals can be clinically utilized. Their approach organizes the products by the mechanism of action: tissue repair, immune response modulation, or antioxidant function. This approach makes sense, and the authors do an excellent job of summarizing the products’ mechanism of action within each category. Unfortunately, the author reaches a similar conclusion for most of the products: the evidence for efficacy is limited. Previous authors suggest guidelines to base our product evaluations: Does the product penetrate the stratum corneum? Is there a plausible biochemical mechanism of action? Are there published peer-reviewed, double-blinded, placebo-controlled trials to substantiate the efficacy claim?³ Most of the products except tretinoin,⁴ and alpha-hydroxy acids,⁵ fall woefully short of these criteria.

The paper’s title suggests that the authors will address the practice of skin rejuvenation with topical therapy. However, the paper does not help the reader in the practical formulation of a skincare program with cosmeceuticals. It would have been helpful for the authors to address the practical aspects of a clinical strategy: How do we best choose from the universe of productions for a given patient? How does the patient’s pigmentation, sebaceous content, and pathology guide the selection of products?⁶ A patient’s subtle observations of irritation, the tactile compatibility of products, the complexity of product application, and lifestyle “fit” are essential, yet subjective contributions to a treatment’s success and also need to be addressed.

The clinical application of a cosmeceutical treatment plan requires attention to numerous details, many of which are frustrating to physicians. A cosmetic and cosmeceutical patient history is time-consuming and keeping up with “trending” products requires constant review. New brands and products are launched rapidly and aggressively promoted on social media, resulting in a tendency for patients to worship novelty rather than focus on long-term success. Working with a licensed aesthetician and other skincare professionals can provide a team that more effectively relates to the patient and takes the necessary time to engage, educate, and construct a skincare plan that reflects the patient’s individual needs.

Significant advances have been made in skin rejuvenation, with topical therapy playing an important role. However, separating fact from fiction with cosmeceuticals continues to be a challenge.⁷ Understanding the science of skin aging and repair is an essential component of clinical practice and the authors contribute to our further understanding. The various products’ theoretic mechanism of action provides context, but as the authors conclude, the lack of studies limit evidence-based product selection. An effective treatment plan requires the analysis of numerous patient and product characteristics that are still mostly learned through trial and error. These complexities and limitations make effective topical skin rejuvenation challenging to achieve and a greater challenge to teach.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.