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THE SECRET SUCCESS FACTOR

How skincare can enhance procedural outcomes exponentially.

To anyone paying attention to trends in the aesthetics industry, all the numbers add up to an unmistakable conclusion: It’s a very good time to be a provider specializing in cosmetic procedures.

According to the American Society of Plastic Surgeons (ASPS), Americans spent over $15 B on cosmetic procedures in 2016, and while surgical procedures made up only about 10 percent of the 17 million total cosmetic procedures performed that year, spending in this category topped $8 B. More telling, perhaps, is the 132 percent rise in the number of procedures performed from 2000 to 2016, suggesting a veritable explosion in market demand.

And its not just women getting procedures, anymore—the number of men seeking invasive procedures has climbed 28 percent since 2000. The male demographic now constitutes 13 percent of surgical cosmetic procedure market share. There is also a shift in the age demographic among individuals seeking cosmetic procedures: although almost 40 percent of surgical and nonsurgical procedures were performed in individuals 35-50 years, 11 percent were in individuals over the age of 65. According to the ASPS, “combined surgical and nonsurgical procedures for men and women 65+ have increased by 89 percent in just five years.”

The truly exciting part, though, is that the upward trends and future projections suggest that the cosmetic surgery and procedure market has not yet reached its ceiling. By 2025, the global market could be worth more than $40 B, bolstered by volume increase and a market infrastructure that not only supports said growth, but that also influences its relevance. For example, one of the suggested drivers of future growth in the cosmetic industry is the exponential expansion in the technology sector, particularly in social media, which in turn appears to be spurring consumer demand for goods and services that impact self-esteem. According to some metrics, the average member of the millennial generation will take more than 25,000 selfies in his or her lifetime. What impact that has or will have on our society is one of the pressing issues of our times. That statistic reveals a trend toward greater beauty consciousness and its inextricable link to self-confidence.

Simply put, market forces suggest that more and more people want to take photographs and they want to look good when they take a picture, largely because they want to be able to share those photographs with friends and family members. Thus, the interaction between growth in social and digital media sectors and the cosmetic industry is synergistic and symbiotic, and it is further buoyed by the fact that consumers also have more disposable income than they have had in a decade. And they are willing to spend on cosmetic procedures, both non-surgical and invasive.

But to focus on the economics of the aesthetics industry ignores the most tried and true of motivators in healthcare. Innovation within the aesthetics sector has produced procedures and techniques that help practitioners meet and exceed consumer demand, which both increases confidence and increases interest in additional procedures.

If there is an unspoken dilemma in all the numbers, though, it is that expectations for outcomes have only intensified, a fact that has led many cosmetic dermatology providers to look for ways to improve healing after procedures, reduce downtime, and extend the effect of both surgical and nonsurgical procedures. The desire by patients to look better with less disruption to their daily lives is a big reason why many practitioners are rethinking their approach to skincare in the periprocedural period. Indeed, evidence increasingly demonstrates that the proper integration of a customized skincare regimen in conjunction with popular cosmetic procedures helps take results to the next level.

Why SkinCare?

Modern Aesthetics® magazine recently interviewed a number of core cosmetic physicians who offer surgical or nonsurgical cosmetic procedures (or both) to learn why skincare is such a hot topic in the aesthetics market. On the face of things, it would seem that dispensing products through the office could be a supplemental revenue stream; yet, almost all of the experts said that financial gains from dispensing were relatively modest. Amy Taub, MD, of Advanced Dermatology in Lincolnshire, IL, who founded skinfo in 1998 as one of the first online dispensing businesses during the Internet’s infancy, dubbed any revenue she sees through that aspect of her practice as a “nice side effect” but certainly not the driving force behind providing customized skincare to patients undergoing procedures.

“I really do not recommend anything unless it will help my patients,” said Dr. Taub. “Yes, I own a business, but it would be no fun at all to make money under false pretenses. I would hate myself and then the money would be for naught as I wouldn’t be able to enjoy the freedom it gave me.”

Today, skinfo is an extension of a skincare boutique that operates in conjunction with Dr. Taub’s clinic. It is a separate, although connected, entity employing mostly estheticians who help patients understand and explore their skin issues and then construct regimens to suit an individual’s skin type, goals, and budget. In that way, it becomes complementary to the cosmetic procedures offered on the clinical side of the operation.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

While there are a plethora of skincare options on the market, it seems there is always an unmet need for new products that address specialized issues. Frequently, cosmeceutical companies launch new brands to complement their current portfolio. Or, as Suzan Obagi, MD, explained it, “They don’t replace lines, they add lines for patients so that once they transition off one line, they transition onto another.”

Dr. Obagi recently worked with Obagi Medical to launch the Suzan Obagi MD line, which, she said, is intended for those individuals whose needs are not exactly met with existing Obagi products. The new line was formulated to defend against ultraviolet rays and help rejuvenate the skin, and the anti-aging benefits are geared to those who may be looking for something additional from their skincare product.

“If you look within Obagi, they have been supporting their Nu-Derm and Obagi C-Rx lines for years. New brands are launched within the same philosophy of existing lines that are really gold standard,” Dr. Obagi said.

“Skincare before a procedure readies the skin, enhances metabolism for the trauma that is coming, revs up the machinery for repair, and adds the nutrients needed for repair. Skincare afterwards gives the skin its best and most optimal chance for healing quickly and without incident while adding adjuvant and possibly synergistic potency to results,” said Dr. Taub.

Another reason to think about periprocedural skincare is that not all problem areas can be addressed at one time with procedures. Cosmetic procedures more often than not target a specific concern, and surrounding skin may still show signs of aging or be affected by separate issues.

“When I’m talking to patients, a lot of times they’ll come in and they’ll be bothered by, for example, the under eye area. They’re looking for a fat transfer or for fillers for the under eye region. Yet the rest of their face has so much sun damage and brown spots, or wrinkles, that even if I enhance their eyes, nobody else except the patient is going to notice that because the rest of their skin draws their attention away,” said Suzan Obagi, MD, an associate professor of dermatology and plastic surgery, and director of the Cosmetic Surgery and Skin Health Center and the Cosmetic Surgery and Skin Health Center MediSpa at University of Pittsburgh Medical Center. “Your skin is like the wrapping on the gift.”

No procedure can stop the clock in terms of the natural aging process. Unless a patient wants to be continually reliant on procedures to reverse signs of aging, skincare products that help the skin build collagen are the best defense. There is tremendous potential to use anti-aging medicine to help individuals with fine lines and wrinkles, but that does not necessarily mean it has to be directed only to older patients.

“My goal is to get patients involved in taking care of their skin at a young age. If they start in their mid 20s or early 30s, I know I can make them look fabulous going into their 40s, their 50s, and their 60s, and so on,” Dr. Obagi said.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

The innovative science behind certain cosmeceuticals might make them applicable to the periprocedural period or as standalone offerings of their own. Amy Taub, MD, recently started offering patients DefenAge, a line of products formulated with synthetic defensin molecules that function to stimulate stem cells to produce new skin. Defensin is usually activated after trauma; turning them on on a more routine basis has tremendous anti-aging advantages. In studies, 90 percent of users saw reductions in visible wrinkles, 91 percent experienced improvements in age spots, 83 percent reported reductions in creases, and 83 percent saw improvements in lines around the eyes. Dr. Taub, who was a principle investigator in a double-blind, placebo-controlled trial that will soon be published, said that the DefenAge trio of products increases epidermal thickness and reduces pore size, hyperpigmentation, and fine and coarse wrinkles, all in a statistically significant fashion.

“The science is compelling,” Dr. Taub said. “Patients love it right away. They like the feel and they also like the results that they see pretty quickly. I haven’t seen a product that has given me such unsolicited feedback in a long time.”

In the era of personalized medicine, where patients are looking for that special touch that enhances their experience, focusing on skincare is also a way to individualize the approach to patient care. Most practitioners who use skincare products with their patients have a standard regimen, but then find ways to match the right product with the patient. Dr. Obagi explained that she likes to encourage collagen and elastin production prior to a procedure, which typically means some form of topical retinoid, including either prescription agents or OTC compounds, such as retinaldehyde. These will enhance collagen building during healing and have the positive effect of shortening recovery time. Furthermore, in a patient who might be prone to discoloration, a skin-lightening agent, such as 4% hydroquinone cream or a vitamin C serum containing hydroquinone, might be a consideration.

Sunblock is another standard in the periprocedural protocol, and for Dr. Obagi that means mineral-based products such as titanium dioxide or zinc oxide based sunblocks, usually around an SPF 50. In addition, she may add alphahydroxy acid or a polyhydroxy acid to enhance penetration of other topicals.

“That’s my go-to as a preprocedure protocol, and it is aimed towards controlling pigmentation, building collagen, and then maybe with the use of alpha hydroxys or polyhydroxy acids, to drive the other two agents in deeper,” Dr. Obagi said.

Brand Awareness

The global beauty market’s veritable renaissance pales in comparison to growth within the specific category of cosmeceuticals. According to some metrics, the global cosmeceutical market topped $40 B in 2017, with a projection to reach more than $80 B by 2023. Such a vast market has all the potential to provide consumers with products that provide benefits, but it also has the potential to cause confusion, or worse, to attract bad actors.

The term “cosmeceutical” has no meaning under the law, and the FDA does not regulate such formulations as a specific class of products. While there are guidelines about how a cosmetic product can be labeled, including what claims can be marketed, the industry is largely unregulated. As such, there may be very important differences between what is found in a big box store and the brands that have been specifically developed for use in medical settings.

Companies that participate in the consumer versus cosmeceutical market are motivated by a unique set of factors. In order to tempt customers and influence purchasing decisions, consumer brands need to generate excitement around their products. Although there are quality products available at chain stores and through online retailers, those companies are not necessarily incentivized to introduce their brands to the rigors of clinical trials.

Meanwhile, reputable professional skincare lines are typically subject to a higher level of testing, both internally and by independent study. Within this realm, brands have lasting power because the demonstrated benefits are not obviated by the introduction of new products; instead of replacing defunct brands, new cosmeceutical brands enter the market to meet unmet need.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

In much the same way a personal trainer adds additional workouts to address a client’s needs, Jason Emer, MD, builds on his core regimen for those willing to take additional skincare measures. For instance, he might add Heliocare, an oral supplement that provides extra sun protection on top of a recommended sunscreen. Dr. Emer is also a proponent of masks: he recommends patients use a retinol or exfoliation mask, especially if there is acne or melasma or if there is interest in anti-aging benefits. In addition, he suggests an exfoliation mask, such as Clean Zyme and Skin Zyme (Jan Marini Skin Care, Inc).

“That protocol is ideally started at least two weeks before we do any peels or lasers. We will customize the approach based on the skin’s condition. For example, if the patient has melasma, we recommend a Luminate mask from Jan Marini once a week to brighten the skin. Or we might add a Cosmelan peel to get more lightening before we start their laser treatments,” Dr. Emer said.

Rosalyn George, MD, of the Wilmington Dermatology Center in North Carolina, admits she was somewhat skeptical about the claims she often heard about cosmeceuticals. Those doubts made her hesitant to introduce products to patients. But once she was in private practice, she began to read the research herself instead of relying on hearsay.

“There is a whole science behind cosmeceuticals and what it points to is that there is very good rationale for using them to enhance the services we are offering,” Dr. George said. “Cosmeceuticals are kind of like the icing on the cake for all of the things we already offer in our office.”

While results with cosmeceuticals can be impressive, clinicians might be wise to scrutinize the evidence when it comes to cosmeceutical brands, especially thinking about whether the claims align with one’s clinical practice and experience. Michael H. Gold, MD, of Gold Skin Care Center in Nashville, said he puts more weight on studies conducted by independent researchers, especially when they garner acceptance to peer-reviewed journals. He looks closely at the methodology of studies to understand whether usage patterns make sense in the context of real-world experience. Regimens that involve use of multiple products applied several times throughout the day may simply be too complicated and unrealistic. As well, while several studies demonstrating the benefits of preprocedure regimens are encouraging, latency between the consult and actually doing the procedure is not always feasible.

“That’s nice in a situation where a patient comes in, has a consult, goes home for a month, comes back a month later, gets the procedure. But, really, a lot of times, patients are coming in and they’re getting the procedure. There is usually not a lot of time for a preprocedure regimen,” Dr. Gold said.

However, while a preprocedure regimen may not be relevant for a patient getting a same-day procedure, it may set them up for success with future options. According to Roy Geronemus, MD, Director of the Laser & Skin Surgery Center of New York, a lot of patients come into his practice seeking a procedure on the same day of the consultation. But skin care is still emphasized, because a lot of those patients are not interested in a single procedure. That patient’s “postprocedure regimen” could be establishing healthy skin for when he or she returns for additional procedures.

Understanding if a particular cosmeceutical is better than another is exceedingly difficult, given a dearth of head-to-head comparison trials in the published literature. One might be able to spot a trend in a study, but without a direct comparison, it is unclear how applicable the product is to patient care.

What is incontrovertible, though, is that professional lines have repeatedly demonstrated superior results versus cosmetic-grade products in published studies. Almost all of the experts interviewed by Modern Aesthetics® said there is plenty of literature to support superior outcomes with cosmeceuticals versus cosmetics. That conclusion really should not come as a surprise, according to Beverly Hills dermatologist Jason Emer, MD, if one considers that cosmeceuticals are typically formulated with a bioactive intended to produce a demonstrable effect.

“Cosmetic products that are unregulated or unstudied usually do not have medical actives, so you are likely not going to see true anti-aging or other benefits. You can go and buy any product from the box store and do whatever combination you want, but it’s the strict medical active combinations that doctors are researching to show results,” Dr. Emer said.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

Skincare need not be overly complicated. In fact, most often, the simpler the better. Rosalyn George, MD, said she does not offer a lot of different products because she does not want to overwhelm patients with a lot of options and instructions. That streamlined approach to skincare also applies to regimens she uses in her clinic.

“The newest one that I’ve started offering in my office is a product from Senté, the Dermal Repair Cream,” Dr. George said. “The reason that I really like it is because it is something I can have patients start before the procedure to start help their skin to get better. And they don’t have to stop it with the procedure, because it’s great for postprocedure, too. I don’t have to add something extra for the patient to purchase and use. It’s a great skincare line and I really like that I don’t have to make a lot of changes after the procedure, which might help with overall compliance.”

Properly designed skincare regimens can yield synergistic effects with several types of cosmetic procedures. For example, studies show that absorption of skin products is 30-50 percent greater after microneedling and nonablative laser procedures. The greater absorption may yield a more pleasing outcome or reduced burden associated with treatment of medical conditions like melasma or acne.

“After we microneedle or even after a Clear & Brilliant procedure, we put salicylic acid, hydroquinone, and vitamin C on the skin immediately. The infusion of products into the skin with laser and microneedling gives you a much better and quicker outcome with fewer treatments,” said Dr. Emer.

Preprocedure SkinCare

Skincare is a major focus in Dr. Emer’s practice. Nearly every patient is offered a tailored and customized regimen, and education is always part of the consultation. Though a proponent of laser treatments, he believes the best results occur when the outcome is not solely dependent on the procedure.

“Getting a laser treatment is like running a marathon: You have to prepare your skin for the marathon. You can’t just laser. It doesn’t matter if it’s a light peel or an aggressive laser, you need to train the skin for best results,” Dr. Emer said.

Dr. Emer has a set skincare program for all patients that starts with vitamin C and a glycolic cream in the morning, and a growth factor, a retinol, and either a lightening agent or anti-aging product at night. He calls that the exercise patient should be doing to derive benefit from the procedures he performs, because no laser, no matter how effective, will contribute important elements to the skin that help it long term.

Dr. Taub stresses that providing a preprocedure protocol is not just pre-work, it is a way to maintain the outcome. “We let our patients know it is their pre-work but also their homework and a way of life if they wish to maintain healthy skin, as well as to protect the investment they are making in their skin by having the procedures,” she said.

As Dr. Obagi put it: “It’s just like any other organ. The skin is the largest organ in the body. When you operate on somebody, you want that organ to be in its healthiest state possible so that they have a good outcome after surgery, whether it’s their heart, their brain, or their skin.”

In addition to preparing the patient for a procedure, skincare also broadens the pool of patients who are eligible for cosmetic offerings. Additionally, skincare does not just have be used for the face—collagen building agents are equally relevant for procedures that address the elasticity on the inner arms or thighs, chest area, or abdomen.

“For me, the chest area is crucial to be treated with proper skincare, because I want to make sure their face, their neck, the V of the chest, and the back of the hands look refreshed,” Dr. Obagi said.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

Skincare products can play an important role before and after laser procedures—whether ablative or nonablative. In both settings, optimal healing occurs when the skin is properly hydrated. According to Roy Geronemus, MD, using the wrong kind of product can lead to detrimental outcomes.

Dr. Geronemus tailors recommendations to the particular procedure, but skincare is always a point of emphasis. In general, he looks for products that will keep the skin moist, are noncomedogenic, and facilitate the healing process. Distributing from the practice improves patient convenience and gives the physician control over what patients are using pre- and postprocedure.

“In the case of the Alastin products, we use their Regenerating Skin Nectar with TriHex Technology during the healing phase after ablative procedures and its seems to aid in healing quite well. What is interesting is if we use it a few weeks prior to the procedure, it tends to enhance the healing process,” Dr. Geronemus said. Skin dryness is a common concern after nonablative procedures. The Alastin products hydrate and reduce redness. “So we are using the Alastin products for both the nonablative and ablative procedures,” he said.

Postprocedure SkinCare

Proper skincare is just as important, if not more so, in the period after a procedure to help with healing and to reduce downtime. The right products give the skin its best and most optimal chance for healing quickly and without incident while adding adjuvant and possibly synergistic potency to results. More importantly, using skincare helps gain control over the healing process.

“We use Senté Dermal Repair after a lot of our laser procedures. It’s particularly useful after nonablative procedures. Another option after certain laser procedures is the Jan Marini Clean Zyme and Skin Zyme or Restorsea Cleanser, which is a fish enzyme-based cleanser. For patients who have sensitive skin, we use MDRejuvena, which is a chlorophyll-based product,” Dr. Emer said. “With a combination of the Clean Zyme and Skin Zyme, vitamins B and Cs, a lightening agent, Senté Dermal Repair, and chlorophyll, the skin heals within hours to days rather than weeks. The redness goes down and the results are more significant.”

That particular regimen might change slightly after an ablative laser procedure, because the skin needs more growth factors to heal properly. Whereas occlusive products become detrimental after nonablative laser, they may be preferable for healing after skin resurfacing or other more invasive laser procedures.

Patients may not be equipped to navigate skincare choices on their own. A product a placed on the skin that causes irritation or a break out might lead someone to think they are experiencing a complication from the procedure, or it may wind up causing an additional issue that the clinician and his or her staff are stuck dealing with.

“Postoperative care is as important as the procedure itself, particularly with ablative procedures,” said Dr. Geronemus. “I don’t want patients using random products on their skin. I’d like to know exactly what they are doing and I think that’s important to get the best possible outcome, but also to facilitate the healing process.”

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

Experts suggest that providing skincare samples has a role, but it may not be all that beneficial for long-term use.

According to Amy Taub, MD, sampling might help gauge patient experience with a product: “If a patient doesn’t like a product—how it feels or smells—then they will not use it.” But patients likely won’t see the clinical benefits during a trial period.

Rosalyn George, MD stopped offering samples, because she wanted patients to understand that “just like I tell my acne patients, it’s going to take three months to really see a big change in their skin.”

Suzan Obagi, MD, believes there is value in having patients sample multiple kinds of sunscreens to make sure it will not cause irritation. In other contexts, skin feel is important, but not the sum total of why skincare products should be offered.

“Each product applied needs to have a function. You don’t just apply something because it feels good. It has to impact something. Is it impacting oil production? Is it impacting collagen building? Is it impacting pigmentation? Is it impacting sun damage? These are the things that we’re trying to do. I’m not going to sell someone a fancy moisturizer just for the sake of making a sale.”

For more invasive procedures, there is sometimes concern about a clean wound environment that supports optimal healing. Increasingly, aesthetic surgeons are adopting hypochlorous acid (HOCl) based products for use in the immediate post-procedure time frame. HOCl-based products, such as the Alevicyn and Lasercyn (IntraDerm), are frequently used as antimicrobial skin preps. In the minutes and days after procedures, the products can be applied at home to help prevent infection by various microbes while supporting barrier repair. A silicone enriched formulation is available to help reduce scarring.

In reality, patients may not only need proper skincare after a procedure, they may actually want direction about what products to use to help with healing and to extend the results. Postprocedure skincare is about more than just protecting the investment in a particular procedure.

“The vast majority of patients we see in our offices, whether it’s for plastic surgery or any cosmetic setting, they are going out and buying skincare afterward, whether we are recommending it or not. But patients can get confused about what to use, and when you give them more of a structured regimen, they heal better from the procedure and they’re more invested in taking care of their skin afterward,” said Dr. George.

“Most patients, once we talk to them, don’t follow their normal routine,” said Steven Dayan, MD, a plastic surgeon in Chicago and Co-Chief Medical Editor of Modern Aesthetics®. “They’re quick to adopt what we recommend; if they’re going to spend thousands of dollars on a surgical procedure, they certainly want to make sure they do the right thing afterwards.”

Getting patients engaged in the care of their own skin and providing valuable education are only some of the benefits of postprocedure skincare. There is also the potential to extend the cosmetic effect, which may be particularly useful for procedures aimed at reversing aging signs, from energy-based devices to injectables. “All patients getting neuromodulators and fillers really should have a good skin care regimen, because even the youngest patient is undergoing aging the moment that procedure is over,” said Dr. Obagi.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

Sometimes patients follow skincare behaviors with the best of intentions, even though the practices they are following might be detrimental to the health of the skin. Here are some common missteps among patients.

OVER RELIANCE ON PROCEDURAL FIXES

“I think a big problem is that people are sometimes doing too much with their skin,” said Suzan Obagi, MD. “These are the patients that are either doing too many procedures, too many peels, too many microdermabrasions, too many lasers, too many fillers, or too much neuromodulator. Then, their skin starts to have issues with sensitivity, irritation, erythema.”

INGREDIENT PHOBIA AND THE MISGUIDED BELIEF THAT ORGANIC IS NECESSARILY BETTER

“The biggest thing I see right now is that everybody’s afraid of chemicals. Patients go and buy anti-chemical things, but that doesn’t necessarily mean that whatever herb they are putting on isn’t an irritant to the skin…Remember, water is a chemical and its not a bad thing,” said Rosalyn George, MD.

“I tell patients not to be afraid of using oils, but use them properly,” said Jason Emer, MD. Patients with perceived oily skin may be over-producing natural oils to combat dryness. “Applying an oil actually decreases overall total oil. Certain oils that have actives, like Restorsea Liquid Gold, can actually be very useful in combinations with certain products,”

AT-HOME DERMAROLLING

Home users may be over-doing it. “Your skin does not need that deep rolling to get results. The majority of the time, the microneedling needs superficial injury to push product into the skin. Very light microneedling at home avoids infection risk. I would much rather a patient do 0.25 or 0.5 microrolling at home rather than really aggressive bleeding,” said Dr. Emer. “I’m also not a big fan of brushes. Vibratory brushes might actually cause injury to the skin and they don’t allow proper penetration of product, and they also irritate people quite frequently.”

FEARING SKIN SIGNS

“I tell patients all the time, ‘Don’t be afraid of redness and peeling. You want exfoliation, especially in the first six weeks of starting a product. It allows for cell turnover. It allows for better penetration of other products, you need to have that,’” said Dr. Emer.

PERIPROCEDURAL SKINCARE IN ACTION: PEARLS FOR PRACTICE

Botanicals are “buzzy” in skincare, but all products are not created equal. According to dermatologist and skincare researcher Carl Thornfeldt, MD, seven pathways of inflammation occur in the skin, that, when coupled with a disrupted stratum corneum, produce the changes that we see as skin aging. Most topical formulations only work on a few of these pathways. “There was no way we could formulate with enough synthetic agents to block all seven inflammatory pathways and up regulate all five barrier repair pathways,” said Dr. Thornfeldt, founder of Epionce. “So we went to the botanical arena because there exist many biologically active molecules that remain in stable, functioning activity that can be formulated together.”

Effective botanical formulations require more than a listing on the label. “It’s just not the presence of a botanical; The issue is whether you can deliver enough of that secondary metabolite—in other words: the active ingredient within the botanical extract at the therapeutic concentration to the specific cell or structure,” he said.

The quality of botanically-based formulations is affected by the quality of the raw materials. How the plant extracts are derived and handled will impact potency. “We developed proprietary ways to purify and stabilize our herbs so that we know what those active ingredients are. We know the concentration. We know what concentration can be utilized by the cell, and how to deliver it to that cell,” Dr. Thornfeldt said, and he pointed to a series of controlled trials that support Epionce formulations.

SkinCare As a Practice Philosophy

A common reason cosmetic physicians refrain from offering skincare in their practices is discomfort around the idea of “selling” products. But if a provider is comfortable recommending certain procedures that address an aesthetic concern, why is it any different for skin care products? One of the fundamental aspects of a consultation is to offer solutions directed at patients’ concerns. Patients are asking for an expert opinion; the benefits of proper skincare can be a natural extension of that.

“Skin care is an everyday phenomenon,” said Dr. Dayan. “Patients come to us to get educated. Whether they get it from you or they go to the store or the makeup counter at the department store, they are going to get skin care. If you can educate about it, it’s only to their benefit. Patients want information. They want to know which way to go after a procedure.”

If approached from an ethical perspective, with education, and in the interest of best outcomes, dispensing is not “selling.” Plus, it is not imperative for providers to ask patients to add extraneous cost to their procedures if budget will not allow.

“If someone says they cannot afford what I recommend I can think about over-the-counter options that might be a reasonable substitute,” said Dr. Taub. “I look at skincare products like a prescription: There are numerous products each with its own qualities and character, and sometimes an OTC option might be reasonable for that particular patient.”

When asked what it takes to be successful with skincare, Dr. Obagi offered that there should be a philosophy set by the physician, and the support team should help patients follow the physician’s plan. “I encourage all physicians to really be in charge of what’s being sold in their office. Be on top of it,” Dr. Obagi said. “You just have to be passionate about the skin. I would advise all my colleagues in the aesthetics industry to read the different articles that have been written about different active ingredients and read some of the review articles. I think when you have an understanding how the skin ages, or how the skin problems arise, and you know how our actives work, then you can feel very comfortable putting together a regimen for a patient. That empowers the practitioner. I think when they don’t have that, they may be iffy about dispensing a product line, or they may not be comfortable.”