A Clinically Based Guide to Selecting Topical Skincare Products
  • Sun, 07/30/2017 - 11:37

The Skin Health and Beauty Pyramid: A Clinically Based Guide to Selecting Topical  Skincare Products



The use of cosmeceuticals by patients is now commonplace. Without consultation and direction from an informed clinician, marketing pressures can lead consumers to make poor product choices that can result in wasted money and unsatisfactory outcomes. Skin professionals need a scientifically based, succinct tool to guide their patients toward best topical skincare practices. The Skin Health and Beauty Pyramid is an educational framework and product guide created from extensive scientific literature and study review on ingredients, formulations and technologies affecting skin biology. This clinical tool can simplify product choices for physicians and clinicians in the pro­ cess of professionally guiding patients toward the optimal use of topical products to achieve best outcomes for skin health and beauty.



cosmeceuticals" are  topical  products  that provide enhanced skincare benefit which go beyond traditional cosmetics known primarily for covering, moisturizing and cleansing the skin. Cosmeceuticals do not have the same regulatory requirements as prescription skincare products and generally lack rigorous clinical trials to substantiate efficacy, potency, or consistency. Cosmeceuticals for skin rejuvenation are now the fastest growing segment of the multibillion-dollar skin care market. Increasingly, cosmeceuticals are being used in professional practices as adjuncts to clinical procedures and prescription drugs as well as stand-alone home treatments.

The subject matter can be confusing for both the patient as well as the provider. For the patient, the market offers products that claim the same aesthetic benefits from different combinations of ingredients at discount (low) or premium (high) prices. For the provider, many have had limited formal education on the topic. Consequently, it can be difficult to sort through the large number of products available to identify those with scientific data to support their efficacy. Of practical concern, discussing and recommending topical skincare products with patients in the midst of a busy  clinic can be time consuming. In addition, physicians who are not yet confident in their knowledge of skincare product alternatives may feel awkward when patients ask for recommendations. As a result, many physicians avoid actively discussing cosmeceuticals with patients. This  leaves  the  patient  without  informed recommendations from their trusted clinician, and uneducated as to how skincare programs may fit into their overall skin health practices.

The Skin Health and Beauty Pyramid was created as a tool to provide basic skincare product education for patients and help busy professionals guide their patients toward choosing an effective skin care program. The Skin Health and Beauty Pyramid was created from an extensive review by thought leaders in the field of aesthetic medicine. This too! is intended for use by the novice as well as the seasoned aesthetic provider to allow patients a fundamental understanding of the ongoing need for photo-protection, as well as the multipronged approach needed to repair cellular damage that is ongoing in a continual process.

The Skin Health & Beauty Pyramid provides physicians, clinicians and patients with a "roadmap'; a clinically based solution to the challenge of attaining optimal skin health and beauty, intended to improve profession al and patient education, simplify product selection and improve clinical outcome. The Skin Health and Beauty Pyramid ingredient and technology  inclusion criteria is supported by credible clinical studies and physician experience. This Pyramid can narrow your search for effective topical skincare products.

The Skin Health & Beauty Pyramid is based on three hierarchal components, arranged in ascending order of priority from bottom to top. The base of the pyramid defines the 'must have daily' fundamental skin protection and repair ingredients and functions that should be the foundation of all skincare regimens. The middle or core of the pyramid defines the ingredients and functions that a patient 'needs to have' to help transform, normalize and rejuvenate skin. The top of the pyramid defines the 'nice to have' ingredients and functions that provide cell stimulation. These are the newer, promising technologies that can help reduce  the  visible signs of  aging and optimize skin health and beauty.


Base of the  Pyramid: Fundamental

Every person concerned about improving skin health and beauty must be committed to a lifelong lifestyle that includes daily protection and repair against sun and environmental exposure, otherwise every step we take to improve our skin health and appearance is undermined  on a continual basis by damage accumulation from environmental exposure. The process of environmental skin damage and the necessary protection and repair roles that SPF, antioxidants and DNA Re­ pair Enzymes play is shown in the Skin Protection and Repair Diagram (Figure 1). The environmental insults to the skin are depicted on the right side of the diagram predominantly solar radiation but also smoke, air pollution and ozone. The bladed dotted line represents sunscreen protection and depicts the relative amount of protection for each insult. For example, the majority of UV-B radiation is blocked by most high SPF sun­ screens, but the level of UV-A radiation blocked is less and no infrared radiation is blocked by topical sunscreens. In addition, sunscreens do not block other forms of environmental oxidative stress such as cigarette smoke, air pollution, ozone and even oxygen itself. Environmental exposure that is not blocked by sunscreen creates toxic free radicals, depicted by blue dots in starbursts in the diagram. Toxic free radicals are scavenged by antioxidants, represented in the diagram by the second defence shield, represented by the "Pac-Man" images neutralizing the free radicals before they can cause damage to DNA and cellular structures. However, antioxidants do not scavenge all toxic free radicals, so some toxic free radicals damage DNA and cellular structures.  DNA that is damaged by free radicals and direct absorption of UV photons of energy is repaired naturally by the body's own natural repair mechanisms including DNA repair enzymes. The body's natural DNA repair mechanism s are indicated in the diagram by the protein enzymes (" green molecules") intercepting the lesions that distort the helix and repairing them to their normal healthy state depicted on the far left by an undamaged DNA strand. The two most common forms of DNA damage that lead to cell mutation and skin cancer are shown in the diagram: cyclobutane pyrimidime dimers (CPDs) and 8-hy­ droxydeoxyguanosine (8 OHdG) lesions. The diagram stresses the need for all three types of protection and repair to minimize DNA damage and maximize skin health.



Traditionally, topical skin protection has been viewed as synonymous with sun protection for the general public, SPF alone is perceived to be the gold standard for skin protection. Skin health benefits of sunscreen  include reducing  the  risk of sunburn from UVB- and reducing the risk of accumulated sun damage that can cause pre-cancerous lesions and skin cancer. Skin beauty benefits of sunscreen include reducing the visible signs of aging caused by UV-8 and UV-A radiation such as fine lines and wrinkles, dull skin, skin laxity, and undesired pigmentation.

Topical skin protection as measured by SPF, even with a UV-A component, falls short in the total picture of skin protection. Sun­ screens agents themselves, whether chemical or physical, simply cannot provide total environmental protection by the nature of their mechanism of action. Sunscreen ingredients function by scattering, reflecting, blocking or absorbing UV radiation before toxic free radicals are formed in the skin. Sunscreen agents are not 100% efficient. Sunscreen alone is not enough because:

(a) Sunscreens are not 100% effective at blocking UV radiation. SPF 45 blocks 98%  of UVB and less UVA radiation.

(b) Most people apply only 25-50% of the recommended amount of sunscreen.

(c) Slightly more than half of the energy from the Sun arrives on Earth in the form of Infrared radiation Sunscreen does not block Infrared radiation which penetrates the skin deeper than UV-8 and UV-A, and causes free radical formation and accelerated skin aging

(d) Sunscreens are not antioxidants and do not scavenge or neutralize toxic free radicals generated from other forms of environmental oxidative stress including those free radicals induced by cigarette smoke, ozone or air pollution.



In 2005 scientists introduced the concept of topical antioxidant protection based on the cumulative oxidative  stress  protection capacity  score of  an antioxidant from multiple tests (or  assays). This concept of  skin protection was established on the entirely different mode of action of an antioxidant as opposed to a sunscreen agent. Antioxidants inhibit environmental oxidative stress by scavenging toxic free radicals. Antioxidants therefore act as a "back stop" to scavenge toxic free radicals formed by the inefficient ability of sunscreens to block all UV radiation or to block any IR radiation, pollution, ozone, and cigarette smoke.

Antioxidants provide skin health benefits by reducing DNA and  cellular structure damage. Antioxidants, dependent on type and concentration, provide multiple skin beauty benefits including promotion of new collagen growth, reduction in the appearance of fine lines and wrinkles, improved skin radiance, reduction in unwanted pigmentation, and an anti-inflammatory effect to reduce skin redness.  Scientists found that use of  a Vitamin  C formulation  demonstrated  a  " clinically visible and statistically significant improvement in wrinkling when used topically for 12 weeks. This clinical improvement correlates  with biopsy evidence of  new collagen formation."  The antioxidant, hydroquinone, is the current gold standard for treating melasma and post-inflammatory hyperpigmentation.  Antioxidants provide anti-inflammatory properties and reduce redness as shown by scientists  using antioxidants found  in  the  whole coffee cherry  fruit  -  Coffeeberry.  In   addition,  antioxidants  can  protect  proteins  from  glycation or carbonylation, which could result in the preservation of collagen, elastin and other proteins.  Antioxidants do not inhibit direct absorption of photons of UV energy on the DNA strand and antioxidants alone are not powerful enough to scavenge or neutralize all free radicals formed as a result of inefficient SPF protection so damage to DNA and cellular structures is not completely abated. Neither sunscreens nor antioxidants repair damaged DNA. Sunscreens and antioxidants are not enough.



DNA Repair Enzymes

New scientific advances have clearly demonstrated that DNA Repair Enzymes play a critical and final step in cell protection against oxidative stress as a result of UV exposure, other environmental sources of toxic free radicals or even endogenous Reactive Oxygen Species (ROS) production. DNA repair enzymes enhance the body's natural DNA repair process. DNA damage can be quantified by measuring the most common UV induced DNA lesions: cyclobutane pyrimidine dimers (CPD) and guanine oxidation (8GHdG).17 The accumulation of DNA lesions (CPD and 8QHdG) can cause cell death, cell mutation and skin cancer.

Scientists reported reduced incidence of  basal cell carcinoma by 30% and reduced actinic keratoses by 68%, compared with  placebo in   xeroderma  pigmentosum  patients  using a topical  applied  endonuclease  DNA  repair  enzyme  for 1 year. And in  2010, scientists  reported  a 45% reduction  in  actinic keratosis after 48 weeks using topical application of an endonuclease DNA Repair Enzyme.   In 2012, scientist further  demonstrated   a   93%   reduction   in   CPD  lesions  with SPF 50 and  one  photolyase DNA  repair  enzyme.  In  2013 Scientists reported a 53% reduction in CPD lesions and a 37% reduction in mutant p53 after 12 weeks use of topically applied SPF 29 plus three DNA repair enzymes: photolyase, endonuclease and 8oxoG glycosylase. Scientists also showed  early  indication  that DNA  repair  enzymes reduced solar elastosis in the dermis, which  could  prevent  visible signs of unwanted pigmentation.  In addition, DNA repair enzymes have been shown to reduce telomere shortening. Scientists used SPF 50 and two DNA repair enzymes resulting in 97% reduction in telomere shortening and 92% reduction in C-FOS expression.

The use of antioxidants and DNA repair enzymes in topical skin protection and repair does not diminish the importance of SPF. Clearly UV radiation is the overwhelming source of oxidative stress in our environment and there is no antioxidant or DNA Repair Enzyme capable of combatting this stress without powerful SPF as a first line of defence. The ultimate purpose of any topical skin protection product should be prevention of DNA damage and preservation of DNA health and vitality. In a recent 60 subject clinical trial, the individual and cumulative contribution effect of SPF, an­tioxidants and DNA Repair Enzymes  in the prevent ion  of DNA lesions  was  demonstrated ;  this protection effect was progressive (additive in one case, multiplicative in others). In summary each of these components contributes towards overall protection, the most protection and repair being provided by a combination of all three critical skin protection components.




Middle of the Pyramid: Transform

Photo damaged skin biopsies show all of the typical cellular structural changes characteristic of accumulated UV damage.

•    Irregular thickened stratum corneum

•    Results of decreased glycosaminoglycans (GAGs)

•  Collapsed fibroblasts, reduced and fragmented collagen and elastin

•    Reduced basal cell division

These  underlying  structural  changes  manifest  as  changes in the skin's appearance, including sallow complexion, increased fine lines and wrinkles, irregular increased skin pigmentation, skin sagging and an overall loss of skin lustre, radiance and beauty and moisture  retention.

Retinoids ( Vitamin A and its derivatives) and Alpha Hydroxy Acids (AHAs) have both been shown to effectively improve these skin changes. Both ingredients, launched in the 1980's, have stood the test of time, undergone numerous clinical trials, and have been proven to be safe and effective ingredients used by clinicians to treat a range of common skin conditions. Although these two ingredients have entirely different mechanisms of action, the resulting visible skin benefits are cumulative and overlapping in appearance.

AHAs, particularly lactic and glycolic acid, have two primary normalizing modes of action: skin moisturization and exfoliation. Although many other ingredients are touted as skin moisturizers, AHAs are unique in the mechanism of action in achieving the final result. AHAs are true skin moisturizing agents, unlike typical moisturizers that are simple oil and water emulsions. These typical moisturizers provide an occlusive skin barrier after application and function to decrease trans-epidermal water loss and thereby increase skin moisturization. Scientists mapped a mechanism of action for AHA skin moisturization and clinically demonstrated that it is based on increased Hyaluronic Acid (HA) deposition in both epidermis and dermis post AHA application. HA, a high molecular weight non-sulfated glycosaminoglycan, is capable of binding thousands of times its molecular weight in water and is the principal component of the Extra Cellular Matrix (ECM) responsible for moisture retention in the dermis and epidermis. Further, it is now known that lactic acid, the bodies' natural cell signal AHA, has a specific  glycoprotein  binding site on the fibroblast that  induces  this  activity.  Increasing skin moisture retention means increasing epidermal and dermal volume, which reduces fine lines and wrinkles and increases radiance. Scientists concluded that with AHAs "epidermal and dermal hyaluronic acid and collagen gene expression were all increased in glycolic acid-treated skin as compared to vehicle-treated controls''.

In addition, AHAs are skin exfoliating agents, decreasing corneocyte cohesion at the lower levels of the stratum corneum, a mechanism of action documented by Scientists in the 1980s.  As skin ages, the dead cell exfoliation rate slows. As dead cells build up on the outer skin surface, they take an irregular disorderly pattern. This irregular skin surface reflects and refracts light that produces dull, sallow complexion. The effect of AHA leads to renewed skin exfoliation and the irregular stratum corneum is cast away allowing for a new dead cell layer to be laid down in  an orderly  fashion -  the  brick and mortar model. This renewed stratum corneum is smoother and reflects and refracts light to give skin a radiant, youthful glow. pH is the determining factor in AHA skin tolerability;  if  properly formulated, AHA products can be used without skin irritation. These two unique mechanisms of action ie moisturization and exfoliation- create visible benefits and explain the popularity of AHAs as skin conditioning agents over the past three decades.

To this date, after nearly 30 years since their introduction in dermatology, there have been no technologies with greater impact for skin health and beauty than the combination of AHAs and Retinoids; hence the patient or consumer looking for transformation of photodamaged skin needs these two technologies in their daily skincare regimen.


Top of the Pyramid: Optimize

The human body is a protein machine relying on roughly 100,000 different types of proteins, interacting and reciprocating, much like the interaction of the gears in a watch, to carry out every function of the human body such as respiration, digestion, and muscle contraction. Machines wear out, proteins wear out; when proteins wear out or break down they produce protein fragments or smaller linkages of amino acids known as peptides. These peptides can then act as cell signal agents to call the cell to action to make new proteins. Everything the cell does is based on protein-protein interaction; receptor proteins in the cell membrane receive messages from the ECM or the cytoplasm by way of molecules that have a unique "fit" like a puzzle piece with the receptor protein that in turn has a unique fit with an effector protein that in turn fits with other proteins that deliver a signal to the cellular DNA- a call to action to transcribe a portion of the DNA strand (a gene) to make something-for example a new collagen protein. Cosmeceutical peptides are newer technologies and hold the promise to modulate much of the functioning of the skin, but the details remain perplexing. Similarly, growth factors are proteins or polypeptides, which have unique receptor sites that also call the cell to action and play a key role in the regulation of cell division and tissue proliferation.  For example binding of Epidermal Growth Factor (EGF) to the cell membrane receptor protein leads to cell division.

There is a lot of discussion in the marketplace about stem cells because these cells are factories for production of cell signalling  peptides and growth  factors so they are often cultured in the lab to obtain the "broth" they live in that is rich in peptides and growth factors. Stem cells themselves are not "living" in a cosmetic formulation but this is often the consumer perception based on erroneous marketing hype.



Scientists, testing a topical skincare formulation containing physiologically balanced, naturally secreted and stabilized growth factor blend concluded that a "total of 78.6% of patients with photodamaged skin showed clinical improvement at 60 days. New collagen formation increased by 37%, and epidermal thickening increased by 27%. This describes  the top of the Skin Health & Beauty Pyramid is considered "nice to have" after the base and middle of the pyramid are fulfilled. The top of the pyramid is like the finishing touch, much like the polish on a sculpture.



With thousands of skin care products to choose from , clinicians and patients can find it hard to distinguish between marketing hype and reliable information. Patients and consumers rely on clinicians for guidance on which products are best for them and their respective budgets. Many skincare brands are based upon a single super ingredient or so-called a 'hero' product. The Skin Health and Beauty Pyramid is a skincare philosophy based on years of clinical evidence and real-world testing. The pyramid shows the highest priority and most fundamental skincare ingredients and functions in the base. Skincare regimens can be effective, simple and affordable when patients use products that address all of the 'must have daily ' base and 'need to have' middle of the pyramid. After the base and middle of the pyramid are fulfilled, then patients can add the "nice to have" top of the pyramid ingredients and functions. The Skin Health and Beauty Pyramid can be used to educate staff and patients because it represents a simple, systematic approach to prioritizing skincare products based on published clinical research and clinical experience. Realizing one's potential for long-term skin health and beauty can be best achieved by following the pyramid.










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