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The Skincare Pyramid

An educational tool to engage and educate patients about anti-aging skincare options from prevention to reversal.
With Mona Gohara, MD


Dr. Gohara is a fellow of the American Academy of Dermatology, an active member of both the Women’s Dermatologic Society, where she previously served on the Board of Directors, and American Society for Dermatologic Surgery where she serves on the Media Relations Work Group. Dr. Gohara works closely with media online and in print to spread the word about skin health. She is in private practice at Advanced DermCare in Danbury, CT, and also maintains a clinical faculty position at Yale New Haven Hospital where she sees patients and teaches residents.

The job of physicians specializing in skin is to treat and educate. Helping patients make informed choices about routine skincare as well as treatment options are of utmost importance. Mona Gohara, MD created a Skincare Pyramid to help guide patients who want to prevent and reverse signs of aging. Ahead, she shares why this tool has been an asset to her patients and practice.

The Skincare Pyramid emphasizes Dr. Gohara’s 360-degree approach to anti-aging, starting with a base of preventive care steps, building up to treatment options for reversal of specific skin concerns.

The pyramid is built on the concept that having a daily, foundational skincare regimen to prevent signs of aging is paramount. This includes use of gentle, hydrating, non-soap cleaners, antioxidants, SPF 30+, vitamin A derivatives, and moisturizers.

“I tell my patients, if you had a twin with your exact DNA, and you start this type of skin regimen, while he or she doesn’t, you’re going to ward off the signs of aging much longer,” says Dr. Gohara.

In showing the pyramid handout to patients, it becomes easy to discuss steps that should be followed in a good morning and nighttime routine. The sheet also provides a take-home reference for when, and in what order, products should be applied for maximum benefit. During the consult, notes can be written on the handout for patients to refer back to at a later date.

The next step up the ladder includes procedures patients should consider every three to four months, or quarterly, such as facials, microdermabrasion, chemical peels, and even some devices. There are many options at this stage, but Dr. Gohara says that these treatments included on her pyramid offer a good, representative, starting point so that patients do not get overwhelmed.

The next rung up the pyramid includes options for reversing the signs of aging: neurotoxins, fillers, lasers, other devices, and body contouring options such as CoolSculpting.

“I actually think that botulinum toxins offer a large element of prevention as well. When you’re not scowling, those lines will be less deep,” Dr. Gohara says. “So sometimes I make a double headed arrow from neurotoxins to the prevention category to emphasize that point.”

At the very top of the pyramid is surgery, which, if considered, will likely be not more than once in a lifetime for a particular area.

Dr. Gohara also includes a box in the top corner of her handout to emphasize exercise, sleep, and a well-rounded diet so patients understand that skincare requires a holistic approach and that those three elements are an important piece of this puzzle.

Why did you decide to create a Skincare Pyramid for your practice?

Dr. Gohara: Number one, it provides a context for the fact that antiaging is a complex topic. It’s not just about a cream or one device, it really is a complex issue to tackle. The pyramid provides a contextual relevance for the patients that they appreciate as we delve into treatment. I analogize it to my patients by asking, “Would you ever go to the gym and just work out your arms? Not likely.” By choosing just one cream or treatment, it is a similar unidimensional approach.

Number two, it puts skin health on an even playing field with the health of other organs. It’s not bloody and gutsy, so people don’t think of it as such, but it is our largest organ. People tend to think about skin health as a one-point-in-time kind of thing. For example, “I have to wear my sunscreen when I go to the beach,” or “I have to put on my acne cream when I’m breaking out.” Ideally, patients should be cognizant of optimizing skin health daily.

The goal is to make skin top of mind by emphasizing the base of this pyramid, which focuses on prevention. Much like a patient would eat well and exercise for cardiovascular health, s/he should do certain things routinely for skin health.

Number three, it provides a reference for the patients, which is important, especially in aesthetic medicine. Patients are bombarded with many different creams and magic elixirs that claim to be the secret to the fountain of youth. The Skincare Pyramid provides trusted information from a reliable source. It puts recommended products in the context of what they’re best used for, which is some reversal, but primarily prevention, and making the skin look good on a day-to-day basis. Which, I might add, is a critical component of patient satisfaction.

If a patient comes back to my office a couple months later and says, “You recommended this cream and I don’t really think I see any difference,” I usually emphasize, with a copy of the pyramid in my hand, “Remember this bottom line, where the cream fits into the scheme of things is primarily about preventing further damage.” Again, the visual puts the cream in context of where it best fits into one’s daily routine.

Do you provide the pyramid to every patient who presents to your office?

Dr. Gohara: I give it to patients who are coming in to do a cosmetic consult, and anyone presenting to the office looking for recommendations on anti-aging products or treatments. If someone wants eye rejuvenation, they will get best results if they choose a beneficial serum (base), get a light peel (middle), and use neurotoxin (top). Choosing one of the three can still get results, just not the best results. This is the message and context I want to relay.

I present it to the patients who are asking about global antiaging, but it’s also for those seeking advice about a specific area that they don’t like. That could happen at the end of a skin check that I’m performing or even at the end of an acne visit. Maybe the acne is now under control, but they’re concerned about scarring and marks. It would be the same approach.

That’s a reason I really like this pyramid. It’s applicable in many different contexts or skin conditions. Although it was developed for the cosmetic patient, one can see how the idea can be salient when treating, acne, psoriasis, or fill in the blank.

The core concept that the pyramid illustrates is that there are daily things that patients should do for prevention of further damage and then there are also the options for reversal as you move up the ladder. Although the content may change, this ideally can be a universal approach in the treatment of skin.

What other benefits does the pyramid provide?

Dr. Gohara: It enhances the patient experience. This piece of paper is a great tool. It makes you sit down with the patient, eye to eye; you engage them, talk to them, draw and illustrate for them. You are relaying the same information that you would have relayed otherwise, but the manner in which you are doing it allows the patient to feel that you’re going the extra mile and truly caring for them. It takes five minutes, we are not talking hours. Setting the stage and doing some basic explaining reinforces the idea that our goal is to optimize outcome, not to sell the next latest and greatest thing. It shows patients that there is some thought that goes into your recommendations, and builds patient rapport.

While the pyramid helps to build patient engagement and offers an opportunity to recommend products and treatments for prevention, does it also open up conversations about future options and why they should be coming back to the office down the road?

Dr. Gohara: That’s exactly right—this isn’t just about what needs to be addressed right now. It really is something that helps to establish a long-term relationship. I can explain what might be good for them right now—what they can do for prevention. I can also relay that they may not need anything for reversal at the moment, but can talk about future options. They keep this in the back of their mind, and return when the time may be more appropriate. Patients are inundated constantly with specials from Medspas and Groupons for anti-aging treatments, but they aren’t provided with the larger context or the the science behind antiaging. By educating patients, you establish a rapport and unique trust that is hard to find in more generic resources.

The whole process is overwhelming. My opening line to patients coming to my office for an anti-aging consult is, “If there was a magic cream that took it all away, why wouldn’t every person in America be using it? We would not be holding that information back from you. It’s not that easy. If that miraculous cellulite serum really truly worked, I would be the first one in line to get it. It’s not that easy.”

There is always a bigger context. To help patients understand a little bit better, I say, “Think about it in terms of a medical condition such as high blood pressure. When we look at the bottom of the pyramid, that’s when you’re eating well and you’re exercising, and you should be doing that every day, regardless. When you get to the top of the pyramid, more toward reversal, that’s when you’re on the medication. That’s when there’s a situation, it’s happened, you’re on the medication, but you’re still eating well and working out, et cetera.”

It helps patients to put antiaging in the context of other medical scenarios, because then they understand that aesthetic medicine is not just about a cream. It is medicine.

Do you include specific product recommendations when discussing the pyramid with patients? And, if so, is there a value to dispensing any of the recommended products in the office?

Dr. Gohara: I do make specific recommendations. I think it’s helpful, because again, patients are really overwhelmed and they are constantly barraged with information about the latest cosmeceuticals, etc. But I like to use the “Old Navy, Gap, Banana Republic” model. They’re all pretty much the same. You can get the same denim at all three places, but one may be a slightly higher quality, and there’s going to be some benefits to that. I offer a range of products at different price points—there may be cosmetic elegance to one that the other may not have. A broad range of effective options is always best.

I offer products that I like and are available for purchase through my practice but also let them know about others, available over the counter. I aim to be respectful of every patient’s financial considerations. Usually I write my specific recommendations on the Skincare Pyramid handout, so that they may take it home.

Does this approach to discussing overall anti-aging strategies also help make the patient be more accountable for their role so they understand they can’t come to you for one treatment to make everything better?

Dr. Gohara: Correct, and that’s what I appreciate. Again, as I said earlier, the Skincare Pyramid is a reference. When a patient comes back after starting a preventive regimen and say they don’t see a difference or improvement, I can say, “Okay, well we talked about all of these things. This one cream that you are using is one part of the plan to prevent further damage. But you could get this laser, which is more likely to reverse the damage, if that spot is still really bothering you .”

We all know that sometimes doctor’s visits are overwhelming. Often the patient will be uncomfortable because they’re nervous or there is a lot of information being presented at one time. It’s good to have a documentable reference such as the Skincare Pyramid on hand, so that accountability is definitely there.

There’s a practicality to the pyramid. And when someone understands something, they are more likely to invest in it.