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