As scientific technology advances in the world of skin research, the plethora of skincare options becomes more confusing to patients and physicians alike. It is well recognized that skincare plays an important role in skin health and beauty, but choosing the correct skincare products for patients can be challenging. Although some physicians have an ethical dilemma about recommending skincare product to their patients 1 because they do not want to take advantage of the physician-patient relationship, 2 many others support the practice of in-office retail when done in an ethical manner.3 4 5
In 2006 I surveyed my patients in the Division of Cosmetic Dermatology at the University of Miami to see if they wanted me to sell skincare products. We found that 100% of them wanted us to sell skincare products because they 1) wanted to make sure they were using the right products and 2) for convenience. Interestingly, many of them stated that even when they were given a product sample they were afraid that they were not buying the proper product in the store. For this reason, I developed guidelines for the University of Miami to follow to ensure ethical skincare retail in the practice setting by improving patient outcomes.6 7 (Table 1) This system has now been adopted by many dermatology practices in the United States.8
1Miller RC. Dermatologists should guard their patients’ purse, not pick their pockets! Arch Dermatol. 1999;135(3):255-56.
2Gormley DE. There is Nothing Wrong with Dermatologists Selling Products to Patients! Arch Dermatol. 1999;135(7):765-766.
3Milstein E. The sale of products benefits patients and doctors alike. Arch Dermatol. 1999;135:851.
4Gold MH. The ethical dispensing of nonprescription skin care medications is useful as we approach the new millennium. Arch Dermatol. 1999;135:851-52.
5Farris PK. Office dispensing: A responsible approach. Semin Cutan Med Surg. 2000;19(3):195-200.
6Castanedo-Tardan MP, Baumann L. Clinics in Dermatology Volume 27, Issue 5, September–October 2009, Page 522.
7Baumann L. Clinics in Dermatology: Ethics in Dermatology: Part II, Volume 30, Issue 5, September–October 2012, Pages 522–527.
8Baumann L. Fitzpatrick’s Dermatology in General Medicine, 8th Edition, 2012, Ch. 250, p. 1343.
The goal of ethical in-office skincare retail is to offer patients a customized efficacious skincare regimen at a reasonable price. In order to achieve this goal, you need to test products for efficacy and properly match them to your patient’s skin type.Patient instructions must be clear so that they will be compliant with the prescribed regimen. If it were only that simple! The difficulty in separating fact (science) from fiction (marketing claims), time constraints with each patient, and the need for staff training can complicate this process. I believe that an ethical skincare retail process involves 10 main steps.
Step 1: Know Your Ingredient Science
There is so much interesting research on cosmetic ingredients, but there is also plenty of hype and misinformation. One important point is that no one ingredient is right for all skin types, even though companies would love for you to believe that their product works for everyone. In this age of customization, the ingredients should be targeted to the patient’s particular needs. Another important rule is that every ingredient in the product is important. There is no such thing as an inactive ingredient. When the first prescription retinoid (tretinoin) entered the market, it contained an acne-causing ingredient known as isopropyl myristate. This may be one of the reasons that patients would break out when beginning tretinoin. It is important to take into account the “vehicle” ingredients when choosing products.
It is also important to understand that it is not just the ingredients that are important but the “recipe” used to combine them. Although the product label lists ingredients, it does not list the formulation’s recipe, which is proprietary and often patented. The “recipe” includes the order that ingredients are added in the process, the pH, the amount of each ingredient, the temperature at which the ingredient is added, and many other important factors that determine the final chemistry. Ingredients like vitamin C, green tea, and soy must be formulated properly to be effective. Many “copycat” brands have similar packaging and identical ingredient lists. Don’t be fooled! They cannot use the patented recipe and therefore, their end product is different.
There is so much to know about individual ingredients that I devoted an entire textbook called Cosmeceuticals and Cosmetic Ingredients to the subject. It’s important for you to understand which ingredients are worthless (like stem cells and peptides) and which ones are crucial (such as retinoids and antioxidants) so that you can arm your patients with products that work.
Step 2: Understanding the Cosmeceutical Formulation
Formulation knowledge (cosmetic chemistry) is required to take ingredients and combine them in a way that enhances rather than hinders their activity. Cosmetic chemists function much like a chef who combines ingredients and uses specific cooking techniques to enhance the flavor and presentation of food. The importance of the ingredient recipe cannot be overstated. Interactions between the ingredients in a formula determines the end product and how effective it is, how elegant it feels, and how it smells. The “cosmetic elegance” of a product influences patient compliance and is directly related to product sales. After all, if it works well but smells bad and feels icky, consumers will not use it.
Step 3: Understanding the Manufacturing and Packaging Process
How a product is made and packaged is crucial. For example, retinol and ascorbic acid break down when exposed to light and air, yet some manufacturing plants use large stirring vats (that resemble huge Kitchen Aid mixers) that allow exposure to air and light. The process of packaging the completed product is also important because this must be done in an air-tight and light-free manner. In some cases, the product is formulated in one place and shipped to another location for final packaging, yet several ingredients can lose their potency during transit. Finally, the container that the product is packaged in is important. Air and light can get into tubes, affecting the efficacy of a product. In addition, the plastics and other material in the tubes and jars can react with the ingredients and affect efficacy.
Step 4: Know Ingredient Interactions
The order in which products are placed onto the skin affects stability, efficacy, safety, and the chemical structure of the ingredients. The order of application and the combination of ingredients is crucial because ingredients chemically react with each other and can inactivate each other. Certain ingredients like fatty acids can also affect absorption. For example, olive oil actually increases penetration of other ingredients because it has a high content of oleic acid, while shea butter (a good source of stearic acid) can decrease penetration by strengthening the skin barrier. Master cosmeceutical formulators carefully consider all of these issues when formulating cosmeceutical products.
Step 5: Properly Identify the Baumann Skin Type® Using a Validated Questionnaire
The process of accurately assessing a patient’s skin type is often arduous because you must ask the patient numerous historical questions. Asking historical questions about the skin’s past behavior is important to diagnose the skin phenotype. Looking at a patient’s skin at one point in time is not as accurate as asking a series of questions about how their skin has behaved in the past under varying conditions. Having an in depth discussion about this will take up time in the exam room and slow down your clinic. A series of questions self administered in the waiting room on a tablet or mobile device can solve this problem.
I use a questionnaire known as the Baumann Skin Type Indicator (BSTI) that assigns the patient to one of 16 “Baumann Skin Type” designations.The scientifically validated BSTI questionnaire questionnaire takes 3 to 5 minutes, does not require a staff member, and assigns the patient to a skin type based on skin oiliness or dryness, sensitivity, evenness
9Baumann L. A Validated Questionnaire for Quantifying Skin Oiliness. Journal of Cosmetics, Dermatological Sciences and Applications. 2014;4:78-84
of skin tone, and risk factors for wrinkles.10 11 12 When these four important parameters are combined, there are 16 possible combinations. The 16 skin types are designated by a four-letter code such as OSPW (Oily, Sensitive, Pigmented, Wrinkle-Prone) or DRNT (Dry, Resistant, Non-Pigmented, Tight).13 Using the Baumann Skin Typing Nomenclature is an abbreviated way to represent an accurate history of the patient’s skin characteristics.14
Step 6: Choose Ingredients Appropriate for the Baumann Skin Type
It is important to understand the characteristics of various ingredients and match those to your patient’s skin type. This should be done ahead of time so that you can speed up your patient consult times. Using a methodology that matches the skin type with a preset regimen allows you to easily and quickly prescribe skincare regimens with ingredients that will help their skin and avoiding ingredients that might worsen their skin.15 16
For example, acne patients who have dry skin from an impaired skin barrier will not be able to tolerate benzoyl peroxide due to dryness and irritation. Oily patients will often not use chemical sunscreens because they are greasy and can clog pores. Wrinkle-prone patients with stinging sensitive skin may not tolerate ascorbic acid, glycolic acid or other acidic products. Choosing the correct ingredients will improve compliance and outcomes.
Step 7: Choose Products Appropriate for Each Baumann Skin Type
There are many factors to consider when recommending particular brands and products for each skin type. When selecting products, pay close attention to the type of research studies the company has done on their products and confirm that the study was done with the final formulated product and not just the ingredient. Also make sure the studies were done on human skin rather than cell cultures or animals. For example, ascorbic acid has been shown to increase collagen production in cell cultures.17 However, in order to feel confident that the product does the same when applied to living skin, studies should be conducted using the finished product on human skin. Ascorbic acid does not penetrate the skin well unless it’s formulated at the proper pH so many Vitamin C containing products
11Baumann L. Fitzpatrick’s Dermatology in General Medicine, 8th Edition, 2012, Ch. 250, p. 1343
12Baumann L. A Validated Questionnaire for Quantifying Skin Oiliness. Journal of Cosmetics, Dermatological Sciences and Applications. 2014;4:78-84
13US Patent 20060265244 A1 Baumann L. Method of determining skin type, choosing skin care products and procedures and promoting skin care products.
14Baumann L. The Baumann Skin-Type Indicator: A Novel Approach to Understanding Skin Type Handbook of Cosmetic Science and Technology, Third Edition (March 2009) Chapter 4.
15Baumann L. Understanding and treating various skin types: the Baumann Skin Type Indicator Dermatol Clin. 2008 Jul;26(3):359-73.
16Baumann L. The Baumann Skin Typing System. Cosmeceuticals and Cosmetic Ingredients (McGraw-Hill 2014) Ch. 1.
17Pinnell S. Induction of Collagen Synthesis by Ascorbic Acid. Arch Derm 1987;123:1684
would not pass the efficacy test if they were tested on intact human skin.18
When designing a skincare regimen for your patient, remember that there is no reason to use every product of the same brand. Companies will tell you that every product in your regimen should be the same brand because they were formulated to go together and enhance each other’s efficacy. The problem with this argument is that each company has a different core competency. Loreal and Elta MD, for example, make great sunscreens and have always been leaders in sunscreen technology. While you would want to choose one of their sunscreen products for your patients, you might want to combine it with a NeoStrata hydoxyacid product. (The founder of NeoStrata was the first to patent the use of glycolic acid for aging skin.) For my patients, I chose the best SKUs from each brand, combine them, and test them on various skin types to see which products and combinations of products work best for each skin type. My patients go home with a regimen composed of 4-6 different bands. I have found that they like this level of customization and personalization.
Step 8: Design the Regimen and Order of Application of Products
Once you have determined your patient’s skin type and matched the proper products to that type, you must tell them exactly how to apply them. Patients often forget what order to use products in. I find that the most common question that I am asked is “Do I put my sunscreen on before or after my moisturizer?” I help them remember by telling them that SPF is always applied on top of the other products so that it is closest to the sun. I always provide a printed regimen with step-by-step instructions for morning and night to ensure compliance. I even give my patients stickers with numbers on them to put on the products. This helps them remember when to use each one.
18Pinnell S, L- Ascorbic Acid Percutaneous Absorption Studies Dermatol Surg 2001;27:137–142
Step 9: Educate the Patient
Take the time to educate your patients on their skin type and skin issues. If you explain why you chose each product, why the particular ingredients are important, and why the order of application is important, they are more likely to be compliant and get better results.
Information about their skin type, skin challenges, and regimen specifics can be developed before the patient encounter to save time during the consultation. Emailed educational newsletters targeted to various skin types can be used to educate patients and keep them informed of new products and procedures.
Step 10: Encourage Compliance
Schedule a follow-up visit after one month to check on their progress. If you prescribed a retinoid, patients may experience irritation and stop using it. This follow-up visit is important to promote compliance. If you have an imaging system, baseline and follow-up photos can help to illustrate a patient’s progress and keep them vigilant.
Four weeks is a good timeframe because patients tend to lose interest at the one-month mark, but most products take 8 to 12 weeks to provide visible results. Emphasize how important the follow-up visit is at the initial appointment, and schedule the follow-up visit before they leave the office.
Streamlining the Process
The skincare retail process must be followed precisely to improve patient outcomes. Most doctors are too busy to put together a methodology for their office. I developed the Baumann Skin Typing methodology for my practice. In late 2014, I founded The Skin Type Solutions Franchise System to overcome these hurdles and save the physician time and money by streamlining the process.19 20 It works like this:
The patient takes the skin type questionnaire and is assigned to one of the 16 Baumann Skin types.
A staff member matches the skin type to the pre-set regimen.
The doctor reviews the regimen and makes any necessary changes or additions (including prescription medications).
The patient is presented with a step-by-step skincare regimen.
The patient purchases the correct products.
The patient is given instruction sheets to increase compliance.
The patient returns in four weeks for follow-up with the staff designee to ensure that the regimen is being properly followed.
Knowledgeable physicians who are specifically trained in cosmeceutical science are the best source of skincare advice because of their unique knowledge of science and concern
20Baumann L. Steps to Optimizing Skincare Retail in Your Practice. Skin and Allergy News July 2014.
for the best outcomes for their patient. Our program educates you and your staff about cosmeceutical science and how to design the proper skincare regimen. Whether you choose to follow the STS system, or develop your own methodology, following this stepwise approach will help you retail skincare in an ethical manner.
Table 1- How to Ethically Sell Skincare Products in Your Practice
Understand cosmetic ingredient science
Ensure product quality
Choose only the efficacious SKUs from each brand
Identify the patient’s skin type using a validated questionnaire21
Correctly match the product and ingredients to skin type
Ensure that the ingredients do not adversely affect each other
Provide exact regimen directions
Provide education to increase compliance
Provide competitive pricing
21Baumann L. A Validated Questionnaire for Quantifying Skin Oiliness. Journal of Cosmetics, Dermatological Sciences and Applications. 2014;4:78-84
Developed by world-renowned dermatologist, Leslie Baumann, MD, the Skin Type Solutions® Franchise System is an educational, science-based skincare store that implements a simple and reliable system to maximize skincare product sales and improve patient compliance and results.
Based on Dr. Baumann’s patent-pending Baumann Skin Typing System, this first-of-its-kind retail model provides dermatologists with the scientific methodology, training, and education necessary to prescribe effective, customized skincare regimens utilizing multiple brands of products that have been independently tested and approved by Dr. Baumann. To learn more about what Skin Type Solutions can do for your dermatology practice, visit the STS site here.