Integrated Skin Care: The Science Behind Improved Outcomes
The idea of integrating skin care regimens with existing in-office aesthetic procedures has long been heralded as a way to enhance patient satisfaction, thereby growing retention and fostering word of mouth referrals. While these benefits already make a strong case for offering a multipronged approach to aesthetic treatments, there may be another reason for practitioners to think about incorporating skin care programs for use before, during, and after in-office procedures: customized skin care programs used in conjunction with office-based treatments may help to improve overall aesthetic outcomes for patients.
A growing body of research shows that patients can experience myriad benefits from integrated skin care programs, including improved patient satisfaction, reduced downtime, and enhanced results. However, using the proper formulations may be the real key to achieving the kinds of outcomes demonstrated in rigorous clinical trials. According to Rancho Mirage, California-based dermatologist Wendy E. Roberts, MD, SkinCeuticals' emphasis on rigorous scientific studies and rationale and the company's efforts to share that data with clinicians, differentiates its products from others on the market.
“Basically, SkinCeuticals is a skin care company for procedural and cosmetic dermatology,” Dr. Roberts said, adding that the ability to point to a study that proves efficacy and tolerability is extremely powerful.
There may also be a more subtle advantage of having SkinCeuticals products tested in clinical trials. Because SkinCeuticals products are specifically formulated and the final formulation is thoroughly tested, the best results will occur when they are used properly. This is incentive for patients to remain compliant with the recommendation from their aesthetic provider and to avoid aimlessly spending money buying products at the cosmetic counter.
But integrated skin care isn't just about the bottom line, it's about the end results. In a recent double blind, prospective, single center, randomized split face clinical trial of patients undergoing fractional CO2 resurfacing, use of SkinCeuticals C E Ferulic was associated with investigator graded results of decreased edema and illustrated favorable directional results for possibly facilitating wound healing versus a vehicle, following the procedure.1 (Figure 1)
The aesthetic treatments offered by SkinCeuticals give clinicians a method to treat sun damaged skin with less invasive approaches to achieve favorable outcomes.
Positive benefits for integrated skin care have also been shown in patients using SkinCeuticals Body Tightening Concentrate for 8 weeks after radiofrequency treatments.2
In 20 females undergoing procedures to address mild-to-moderate skin laxity on the posterior thighs/buttocks, patients were randomized to use Skinceuticals Body Tightening Concentrate on one side. When blinded investigators graded the outcomes at the conclusion of the 12-week study, the area treated with the topical agent showed a statistically signiﬁcantly greater degree of improvement than the side where no topical agent was applied.3
Another application in the context of surgical patients, according to Patti Flint, MD, FACS, a solo practitioner in Scottsdale, AZ, is for patients undergoing breast augmentation or procedures on their body. Dr. Flint, who estimated that about 60% of her practice is surgical, uses a three-step regimen of an antioxidant serum, a sunscreen, and a retinol in almost all patients, and skin tightening and retexturing serums may be added to help with healing, especially during fat grafting procedures that may induce flaky, dry, itchy skin at the harvest site.
Offering patients potentially faster recovery is a tremendous benefit on its own, but there may be another appeal to using skin care products during the healing phase. “Patients prefer to be a part of their recoveries, and if you provide them with direction, they're generally fairly religious about following instructions,” said Dr. Flint.
Proven Protocols for Enhanced Outcomes
Several of the panel members at the roundtable said that skin care is fast becoming an integral part of their practices, whether they focus more on surgery or non-invasive procedures, and regardless of whether they consider themselves strongly aesthetic practitioners or more inclined to medical dermatology. The reason, they said, is because patients are increasingly looking for faster recovery time, less down time, and a quicker return to their life and activities—all the while expecting superior aesthetic outcomes with just about any treatment. Meeting that demand requires a comprehensive approach, including potentially adding a skin care program that enhances results.
One procedure that appears particularly amenable to integrated skin care programs is facelifts, already one of the most frequently performed cosmetic procedures in the United States, with recent data suggesting it is continuing to grow in popularity.4 According to the panel, patients receiving a facelift are likely to benefit from use of an antioxidant, such as SkinCeuticals C E Ferulic or Phloretin CF with H.A. Intensifier (HAI)—a multi-modal facial serum containing hyaluronic acid (HA), Proxylane (C-Xyloside), purple rice extract, and dipotassium glycyrrhizate. The proprietary combination of ingredients has been shown to increase HA in the skin.
Studies suggest that H.A. Intensifier can play an important role for patients seeking answers to aging concerns. In a 12-week, single center, clinical study was conducted on 59 women with mild to moderate photodamage, HAI use yielded statistically-significant improvements in all of the tested facial skin attributes (at week 12), stratum corneum hydration (at week 12), and transepidermal water loss (at week 12).5 Furthermore, PCR analysis in a subset of patients showed a significant increase in hyaluronan synthase 2 and collagen type 1a1 after 12 weeks of application, two components used by the skin to produce hyaluronic acid.
Because of the demand for quality results with less down time, the category of minimally invasive procedures has become increasingly popular, with microneedling emerging as one of the hottest procedures in the aesthetic marketplace. Microneedling can achieve impressive results and help reduce the signs of aging. SkinCeuticals has shown that the use of skin care in the period after microneedling is safe.
The SkinCeuticals Microneedling Device Protocol is intended to address this very need: 2-3 drops of Hydrating B5 Gel at the start of the micro needling process is intended to help with device glide and theoretically boost hydrating effect. Then, SkinCeuticals C E Ferulic is applied to the treatment area, and either a Phyto Corrective Masque or a Biocellulose Restorative Masque can be added. In the following weeks, Phyto Corrective Gel is used to help correct any missed spots and Physical Fusion UV Defense SPF 50 sunscreen helps protect against sun damage, when used as directed with other sun protection measures.
For filler and neurotoxin patients, patients' overall skin health and a proper regimen afterward may help enhance the effect. In a 3-cell dermatologist-controlled 14-week clinical study, SkinCeuticals protocol (consisting of Advanced Pigment Corrector twice daily, plus Phloretin CF, Retexturing Activator, Retinol 0.5, and Physical Fusion UV Defense SPF 50) in conjunction with aesthetic injectables was proven to improve the appearance of skin tone (ie, visible improvement in fine lines, skin tone, and radiance) by 66% and reduced the look of discoloration by 67% as graded by investigators.6
While injectables can be used in many areas around the face, they are most typically used in the periorbital area. Due to the thinner skin in this region and decreased vascular supply, some of the earliest signs of aging appear around the eyes. According to the panel, SkinCeuticals A.G.E. Eye Complex is complementary in correcting the visible signs of aging. In a 12-week study conducted by SkinCeuticals, A.G.E. Eye Complex, an advanced anti-wrinkle eye cream that improves the appearance of dark circles, puffiness, and crow's feet, significantly improved the appearance of key visible signs of aging, including 29% improvement in puffiness, 27% improvement in dark circles, and 33% improvement in skin firmness and elasticity.
Customizing the Skin Care Regimen
Some skin care additions are relevant for most every patient—such as antioxidant and sunscreen. Yet the greatest benefit of integrated skin care derives from customizing the approach to the needs of the patient. In individuals with rosacea, for example, the right product can make all the difference. In cases where Retin-A (tretinoin) tends to dry the skin, which dissuades patients from complying with a skin care regimen, a lipid moisturizer, like Triple Lipid Restore, can help those patients retain moisture in the skin and provide even looking skin, even with ongoing retinol therapy.
A similar phenomenon is true for acne patients: SkinCeuticals C+AHA may help smooth the skin and provide a glow despite harsh acne therapy, and the options abound for customizing therapy for these individuals. In the practice of Jennifer Ahdout, MD, FAAD, a dermatologist in Beverly Hills, CA, patients treated for acne are matched with an appropriate cleanser and sunscreen; then, if any of the products might dry the skin, they are also provided Skinceuticals H.A. Intensifier. If more aggressive treatment is necessary, including procedures such as lasers, use of a SkinCeuticals Phyto Corrective Masque has been proven to topically reduce the skin surface temperature, leaving patients more comfortable.
“Using Phyto Corrective Masque in the office, possibly in combination with an antioxidant, is a great option because it helps calm the skin after a peel,” said Dr. Ahdout.
The additional healing effect of an integrated protocol is also applicable to laser applications, such as broad band laser (BBL) or intense pulse light (IPL) therapy, where the risk of phototoxicity may be a concern. Data suggest that the use of C E Ferulic in the period immediately following fractional ablative laser procedures may reduce the incidence and degree of erythema and edema patients experience. In the split face study, the control side showed reduction in expression of basic fibroblast growth factor (bFGF), which is associated with wound healing, at day 5 and 3 months. However, the side treated with C E Ferulic showed no such reduction.1
Additionally, the panelists agreed that SkinCeuticals hydrating B5 gel or Phyto Corrective Masque applied immediately post-procedure helps cool the skin, providing the patient an almost instantaneous sensation of relief from the application of laser. These observations align with data from a clinical study conducted by SkinCeuticals, which showed that topical application of Phyto Corrective Masque to the face following 1550nm non-ablative laser treatment reduced skin surface temperature by about 4°F compared to the untreated side as measured by thermal imaging.
“When I do aggressive resurfacing I don't want patients to go and buy something that is going to give them a contact dermatitis or irritate them,” said Dr. Ahdout. “I want to provide them with recommendations of products I have studied and qualified for this purpose, especially if they're undergoing an aggressive treatment, because if they are going to dedicate all this time to heal and invest in the procedure, then I'm going to start them on a product to decrease their down time.”
Skin care programs, though, are not always the complementary element of a patient encounter, and sometimes they are the primary reason patients come into the clinic. Several of the panelists said they have been treating patients in their practice for multiple decades, with skin care regimens being a central focus along the continuum of care. In some cases, integrated skin care made individuals more comfortable with the provider, thus leading to sampling additional offerings. In other cases, patients who underwent a procedure kept coming back for skin care tips but then converted to a second or third procedure much later. That's because the goal of the skin care program, and thereby the products used, can evolve and change over time. For example, patients in their 20s or 30s might benefit from more protective measures against wrinkle formation and sun damage (say, C E Ferulic, MetaCell Renewal B3, and a Skinceuticals Sunscreen). By the time patients enter their 30s and 40s, they may start to look toward laser procedures and injectables to help prevent the first signs of aging, which is an excellent time to introduce the use of SkinCeuticals H.A. Intensifier. For individuals in their 40s and 50s, the neck area begins to become a concern, and so neck firming creams, especially combined with radiofrequency treatments, are a definite option, as is SkinCeuticals A.G.E Interrupter.
In fact, several panelists emphasized skin care programs designed to address signs of the aging process. Jason Emer, MD, said his typical protocol for patients concerned about signs of aging is a vitamin C and glycolic cream in the morning and a retinol at night. He then builds off of that. If there are signs of pigmentation in Fitzpatrick type III, IV, or V skin, he will add kojic acid in the morning and hydroquinone a few times a week at night. Older patients, those with dry skin, and patients who undergo multiple procedures will likely require a moisturizer and/or a lipid protective barrier. Dr. Emer also utilizes masques with his patients, which he will customize to the patient's needs, retinol if they have acne or fine lines, a lightenting masque for pigmentation issues, or a stem cell masque that he formulated in his office for those individuals interested in anti-aging treatment.
“I tell patients that tretinoin is better for a medical condition and retinol is better for cosmetic,” Dr. Emer said. “We do tretinoin only twice a week, and retinol the rest of the time.”
The underlying point, according to the panel, is that skin care regimens offer countless opportunities to personalize the approach to treating patients, especially when the products used are backed by strong science. Kelly Killeen, MD, who practices at Cassileth Plastic Surgery, Beverly Hills, CA, said her practice is primarily surgically focused. Yet, she still emphasizes skin care as a way to individualize and customize patient care.
“It actually builds a connection with the patients because they want that personal care,” Dr. Killeen said.
Perspectives on the Added Value of Integrated Skin Care
As aesthetic medicine has evolved from providing beauty benefits to offering patients a way to enhance well-being, the importance of ensuring patient satisfaction with their experience has become increasingly relevant. Ultimately, though, patients desire a good outcome that will last a long time, a factor that has led Dr. Flint to adopt the use of SkinCeuticals protocols to help enhance the results she can achieve as a surgeon.
“A lot of my patients are middle-age and older with a lot of actinic damage, and so integrating skin care provides me better material to work with on facelifts and helps patients preserve their treatment results,” she said. “It may not matter if I do a procedure that fixes the jowl if all anyone is looking at is the big brown blotches on the patient's skin and surface wrinkling. I think if you can make the canvas look better, your results are better, you look better as a surgeon, and your patients are happier.”
In a study, use of SkinCeuticals Advanced Brightening System kit in conjunction with injectable fillers was associated with greater overall ratings of aesthetic improvement by blinded evaluators, compared to use of bland skin care. Additionally, those individuals who used the Advanced Brightening System kit rated their appearance better.6
Many of the panelists stated that they are able to achieve excellent results with the procedures and treatments they offer—but that they become that much better when they are coupled with an integrated SkinCeuticals skin care program.
“I did an oculoplastic fellowship, so a lot of patients come to me for consultations for blepharoplasty,” said Hisham Seify, MD, PhD, of Newport Beach, CA. “A lot of these patients may not realize that the blepharoplasty will only enhance one aspect of their appearance—that the jowls may sink and the pigmented areas may start to become more apparent. They may or may not be ready for another procedure, but there is always a role for skin care for those individuals.”
There are other, perhaps less tangible benefits of integrated skin care. Dr. Flint expressed that skin programs are a nice option for patients who may not be amenable to surgical options; similarly, skin treatments can be offered to current surgical patients who are focusing on one cosmetic area with a procedure but also have concerns for another part of the body. In addition, Dr. Flint said, skin programs are also a good litmus test for compliance—those who are not adherent to basic skin care programs may not be good candidates for injections or laser treatments that might be associated with rigorous after care.
That is a sentiment echoed by Dr. Emer, who said he requires patients be compliant with suggested skin care protocols before even scheduling them for a procedure. The reason, he said, is that good skin care prepares the skin for the procedure, in much the same way that a runner must train before embarking on a marathon. That philosophy, he said, is as relevant for patients with aesthetic goals as it is for those with medical concerns.
“We have a lot of patients now coming to us with damaged skin or who had bad experiences previously, and most of the time, we hear them say they were never given a proper skin care protocol,” Dr. Emer said. “But when they see the results from the skin care aspect, they start to really trust you and are more willing to try other treatments.”
Trust is also an important aspect for Los Angeles-based dermatologist Helene Rosenzweig, MD, FAAD, who believes proper skin care enhances what aesthetic offerings can achieve. “If a patient comes in and requests injectables, we talk about skin care to prepare their skin before injecting them,” Dr. Rosenzweig said. “You wouldn't want to plant flowers—you wouldn't want to do your Botox—until you weeded out the garden. And so we talk about sunscreen and other good skin health practices, we screen for skin cancers, and then after we have prepared the skin, we slowly get into the procedures that we do.”
Several of the panelists said the sense of trust built around integrated skin care might be one why patients are willing to try other offerings in the practice. The dedication to comprehensive outcomes and improving patients' experience demonstrates that the clinician is doing everything possible to help achieve the desired cosmetic and aesthetic outcome.
Yet skin care as a segue to other offerings is only one dimension of integrated skin care. Many of the patients Dr. Seify works with come to his practice because they need revisions or repairs of prior procedures. As a specialist in cosmetic and reconstruction breast surgery, he often helps female patients who are dealing with aesthetic concerns after battling cancer or previous unsuccessful surgeries.
“A lot of my patients come to me because they need to fix difficult cosmetic or reconstructive problems. Adding integrated skin care to their management enhances the service I deliver to them and gets them to have a better outcome,” Dr. Seify said. “I also have been using skin care as a way to help my cancer patients feel better about the experience when they're going through radiation and chemo, because there are so many horrific things that happen to your skin when going through chemo and radiation.”
Introducing Skin Care to Patients
There is a final important element of integrated skin care to consider: it may not be sufficient to simply offer products in the office or make general suggestions during the patient encounter. Rather, the best results occur when the emphasis is on education about specific products and protocols.
“I've come to realize that it is actually our responsibility to properly educate patients about this topic and to give them the tools to achieve the best possible outcome,” remarked Dr. Ahdout. “I think if a skin care program is something that you use yourself, when you present the idea to the patient, it's very sincere and comes across genuinely.”
Because there is so much information to impart to patients, how the topic of skin care is introduced to patients is important. Some of the panelists said they use questionnaires or inquiries on the intake form to ask about patients' areas of concern. Others said they empower medical assistants and nurses to ask those kinds of questions. Regardless of how it is done, these kinds of queries can serve to identify patients' concerns and prompt discussions about additional procedures.
Some use a pre-printed form that can be filled out with specific product recommendations after the evaluation. Most often, that list is provided to an aesthetician or medical assistant who meets the patient while he or she is preparing for a procedure; but if no procedure is planned for that clinic day, it still might be a good idea for the patient to meet with a staff member knowledgeable about skin care topics so they can get acquainted and get educated.
SkinCeuticals protocols are also easily accessible and applicable tools to use in the clinic. For instance, the company has published protocols based around microneedling, anti-aging, brightening, and to nourish and hydrate the skin. These straightforward protocols help demystify integrated skin care and can serve as a starting point for introducing integrated skin care to the practice.
Another way to introduce skin care to patients is to set aside time during the appointment for a mini-facial that is included in their service. Some of the surgeons on the panel schedule a skin care consult one month after a surgery, which gives patients an opportunity to build on the results they are already in the process of achieving. The SkinCeuticals Skinscope LED, which reveals visible and underlying skin imperfections, including accumulated sun damage (lentigines), oily skin and congested pores, dehydrated and thinner skin areas, uneven texture, and poor desquamation, may be useful during such encounters to start the conversation. In a similar fashion, before and after photography lets patients know how their skin care regimen is benefitting them.
Whether or not to bundle skin care products into the price of the procedure may be practice specific. However, there appear to be some benefits to bundling. On the one hand, it ensures patients will leave the office with product. As well, it has the effect of conveying the overall commitment to achieving the best possible outcome: patients readily get the sense that the injection or surgery alone will not get them to where they want to be, and that use of skin care products is integral to their outcome.
In aesthetic medicine, results matter, but outcomes can be measured by a number of variables. In today's competitive market, patient satisfaction is an important factor in how patients judge the competence of their provider. However, nothing substitutes for a quality and long-lasting result, especially when the treatment is minimally disruptive to patient lives.
“Skin care really opens the door for everything you can do as a dermatologist or plastic surgeon—and not only with non-invasive treatments, but also surgical treatments as well. Because, when patients start to see the results, it earns a sense of trust and they will want to do everything else with you,” said Dr. Emer.
Perhaps more importantly, added Dr. Roberts, failing to discuss skin care may be a lost opportunity. “Data show that the OTC skin care market is large and expected to grow. My patients are obviously purchasing products. So why not buy that from me?” she said.
While many of the panelists work in private practice, integrated skin care may also be relevant for those in academic settings. Arisa Ortiz, MD, who is Director of Laser and Cosmetic Dermatology and an Assistant Clinical Professor of Dermatology at the University of California, San Diego, has found that many of her patients buy products, but often lack the proper knowledge to purchase the correct product. She makes a point to address skin care and offer advice and insight.
“How I present it to them is ‘you're investing all this money on these procedures but you need to protect your investment,'” Dr. Ortiz said.
Better outcomes. Reduced downtime. Increased patient satisfaction. Greater retention. Conversion to additional treatments. These are some of the myriad benefits of integrated skin care, principles that are equally applicable to private practice and academic medicine, and equally relevant for practitioners who focus solely on aesthetics and for those who also offer medical dermatology services. According to the panelists, offering skin care programs conveys that the clinician is doing everything possible to achieve the desired outcome. In turn, a comprehensive approach to treatment strengthens the relationship patients have with their provider.
1.Waibel JS, Mi QS, Ozog D, et al. Laser-assisted delivery of vitamin C, vitamin E, and ferulic acid formula serum decreases fractional laser postoperative recovery by increased beta fibroblast growth factor expression. Lasers Surg Med. 2016 Mar;48(3):238-44.
2. Geronemus R, Du A, Yatskayer M, et al. Enhanced efficacy of a topical antioxidants regimen in conjunction with a home-use non-ablative fractional diode laser in photodamaged facial skin. J Cosmet Laser Ther. 2016 Jun;18(3):154-61.
3. Goldberg DJ, Yatskayer M, Raab S, Chen N, Krol Y, Oresajo C. Complementary clinical effects of topical tightening treatment in conjunction with a radiofrequency procedure. J Cosmet Laser Ther. 2014 Oct;16(5):236-40.
4. Tadisina KK, Chopra K, Mohan R, Singh DP. Nationwide incidence, cost, and epidemiologic trends in facial rhytidectomy: an examination of inpatient facelifts using the Nationwide Inpatient Sample (NIS) database. Aesthet Surg J. 2015 Nov;35(8):NP266-8.
5. Raab S, Yatskayer M, Lynch S, Manco M, Oresajo C. Clinical Evaluation of a Multi-Modal Facial Serum That Addresses Hyaluronic Acid Levels in Skin. J Drugs Dermatol. 2017 Sep 1;16(9):884-890.
6. Dayan S. Integrating Skin Care Into An Injectable Practice. Modern Aesthetics. July/August 2015: 46-48.