Our expert panel provides recommendations on a range of skincare products for different indications, including sunscreens, growth factors and antioxidants
Q: What are your top three products on the market for anti-ageing, and why?
Dr Carl Thornfeldt: The difficulty we have in recommending products to patients, particularly in the US, is price point. If they want a product that has some measurable benefit but price is an issue, I’ll recommend a NeoStrata-type product, something with a primary alpha hydroxy acid (AHA) and a retinol-containing product. There are several on the market. If they want the best product on the market—the one, in my eyes, that has the most efficacy and has beaten all the prescription products—I would always choose Epionce.
Dr Joe Lewis: First of all, I’m not a doctor. I’m a chemist. For any anti-ageing skin care regimen, at the very base of my anti-ageing skin pyramid is skin protection. You have to have a great SPF and antioxidant for DNA repair. That’s fundamental. If you’re not going to do that, you’re wasting your time with the rest of the regimen. That’s a consumer must-have.
What the consumer needs is a combination of a retinoid and AHA. These two ingredients have been the absolute pillar of dermatology for the last 30 years and for good reason. They really work and they really have an effect on the epidermis to decrease the appearance of lines and wrinkles. At the top of the pyramid are the “new age” ingredients, peptides and growth factors. You can get all of these ingredients in Priori or PrioriMD products.
Dr Beth Briden: I agree with the skin care model of retinoids, AHAs, antioxidants and sun protection. My top product is Skin Actives—this combines all ingredients in only two specific creams.
There is a double-blind placebo-controlled study published in Drugs and Dermatology Journal in 2012 showing the clinical and histologic effects of this regime. The product contains alpha, poly and complex poly (bionic acids) along with 1% retinol. The active ingredients are used synergistically and combined with N-acetyl glucosamine (NAG)—the main building block of hyaluronic acid. When retinol is combined with the NAG, it increases collagen production dramatically.
The products also contain potent oxidants including Chardonnay grape seed extract, which is more potent than C and E combined on the ORAC scale, as well as a broad spectrum SPF 30 in the morning product.
The products have all been formulated to ensure maximum compatibility and effectiveness. Each individual ingredient was tested scientifically and in a clinical study by itself and then together to ensure its effectiveness. I think it’s easier to use one or two products, such as morning and night creams, to get all the anti-ageing benefits rather than picking three or four differently-branded products to layer on without knowing if they’re compatible or if they’re cancelling each other out.
Dr Zein Obagi: We have to consider multiple factors when we address ageing. We have to make sure the product contains not only retinoic acid, retinol and a fruit acid, but also an anti-inflammatory agent. Ageing is an inflammatory process and if you cannot repair damaged DNA, the cells will not function.
If you don’t suppress inflammation, the cells will not function optimally and the anti-ageing benefits of any topical agent will not work. I use retinol as a hero and retinoic acid as a therapy. Anti-ageing is not only using a substance; you have to know how it’s formulated, how much to use, when to use it and the synergistic effects. Retinol alone will not work if you don’t also load the skin with an anti-inflammatory agent and an anti-oxidant.
In terms of products, ZO Skin Health uses retinoic acid and retinol. I advise patients to load the skin with antioxidants in the morning, and to load the skin with retinol at night as a preventative measure. If you are doing therapy, fruit acid facilitates the penetration of certain retinoids which helps these products address damaged DNA and inflammation.
It seems like the same retinols and technology have been used for the last 20 years and there has been no development of treatment. New investment in skincare is going away from retinols.
Dr Joe Lewis: There is a huge amount of clinical support for the efficacy of AHAs and retinoids. You can say both ingredients plump the epidermis, which pushes out fine lines and wrinkles. However, they do it by different mechanisms of action. With AHAs, we have a huge increase in glycosaminoglycans in the skin and more water—the raisin and grape effect. The raisin has no water so it shrivels and has wrinkles. If you pump water into it, it plumps up and you have a grape. This is how AHAs work.
But retinoids increase the number of cells in the epidermis, so increased epidermal volume comes from increased cellular mitosis. The increased epidermal volume from AHA comes from increased moisture content, so the two together make a great marriage. But peptides and growth factors are the new thing. We now know the cell membrane is the brain of the cell—effector proteins and receptor proteins transfer messages to the DNA, deciding what’s transcribed and what proteins you make. We’re all protein machines, making 100,000 proteins that runs everything in our body, so all this is important too.
Q: Which growth factors do you think are the most effective?
Dr Joe Lewis: One of the problems with growth factors is delivery. I’ve been involved with a lot of drug delivery technologies and the big question is how do we deliver these growth factors to have the maximum benefit? Does it work through a second messenger system? Is it being selectively absorbed at the follicle because the layer of stratum corneum is at its thinnest as you go into the follicular orifice?
We know there are benefits to their use but is it really worth the price for what you’re getting and do we really understand how they work?
Until we have a good, solid delivery system and corresponding explanation for it, I’m very sceptical of growth factors. The reason AHAs and retinoids have been used for so long is because there is such a huge body of evidence supporting them. Nobody doubts they work.
Also, how do we get the best result? We found in basic research at UC San Francisco that the driver for skin ageing is the damaged stratum corneum barrier which activates chronic, not acute, inflammation. The way to attack that is to optimise barrier function and reverse chronic inflammation with ingredients that deliver at therapeutic concentrations to the cell at the site you want to modulate.
Q: What are your top three choices of sunscreen products?
Dr Carl Thornfeldt: My three choices are all anti-inflammatory sunscreens: Epionce Ultra Shield SPF 50, which was the first anti-inflammatory sunscreen on the market; Aveeno SPF 60 for babies; and the Neutrogena Full Spectrum 100. All three are among the other four anti-inflammatory SPF50 or higher sunscreens. A review in 2012 published in the Journal of American Academy of Dermatology showed that three or less anti-oxidants added to sunscreen provide no additional benefit; however, when seven anti-oxidants and anti-inflammatories were added, there was additional benefit.
Dr Joe Lewis: I disagree with that evaluation. In that particular study, we clearly demonstrated the addition of antioxidants to a sunscreen had added benefit.
Another study I’ve worked on combined SPF 50 and an antioxidant—in this case, 1% chlorogenic acid—and the addition of DNA repair enzymes at various concentrations to show the cumulative effect in the prevention of cyclobutane pyrimidine dimers (CPD) and 8-oxo-guanine (8OG) lesions. These are the primary cause of cell ageing, leading to mutation and skin cancer.
You can also now get great sunscreens in mineral formulations, such as CoffeeBerry and a PrioriMD formulation based on chlorogenic acid.
In terms of SPF, after you get past SPF 30, you really need an antioxidant and DNA repair. The SPF 50 used in most studies originated from a FDA council recommendation of a maximum number. But Neutrogena markets the SPF 100 and it’s a good product.
Dr Beth Briden: I like to distinguish between facial and body sunscreens, for daily use, and for activities. For facial sunscreens I like Revision Intellishade. It has a green tea antioxidant plus a broad spectrum sunscreen. It’s tinted so patients don’t have to use a self-tanner to have some colour. SkinCeuticals has a nice physical mineral block and Skin Actives has a daily SPF with potent antioxidants for daily use.
For the body, I like a waterproof broad spectrum, UVA, UVB sunscreen with a sun protection factor of 30 or more. In the US, all sunscreens are regulated so brands aren’t as important as they all had to prove their sun blocking ability. I agree that sunscreens containing antioxidants are more effective, but, they are also more expensive, and cost can be an issue when covering the whole body. Neutrogena is probably one of my favourite brands as they have a great variety of products from gels, creams and sprays with a broad range of SPF factors. For the body, I like the waterproof spray sport versions of Coppertone and Banana Boat as they’re lighter and easier to apply with a quick spray. You just have to apply enough sunscreen to give the benefit.
Dr Zein Obagi: Sun damage and skin cancer are the most problematic skin problems we face.
They are on the increase, no matter how high the SPF. I do not agree that antioxidants don’t make a difference—they will make a big difference. But you have to distinguish how to apply sunscreen in two steps; first, load the skin with antioxidants and then apply sunscreen with SPF 30 and natural melanin.
ZO Skin Health Oclipse Sunscreen + Primer SPF30 is a sunscreen that addresses inflammation and the antioxidant issue. We don’t use chemical products; we use natural melanin, titanium dioxide and zinc oxide for broad-spectrum UVA/UVB production. We want to lengthen the sunscreen’s efficacy.
There are two Oclipse products—a tinted sunscreen oxidised melanin and a non-tinted fractionated melanin version. If you apply a sunscreen, no matter how high the protection, the SPF will come off in an hour and a half. The melanin is a very important issue, to protect the melanocytes from a negative response to UV exposure.
Dr Beth Briden: There is also an oral sunscreen for patients who are out every day in the sun. Heliocare capsules with the fern extract polypodium leucotomos, a very potent antioxidant to help protect against UV damage. But as this is taken as a daily supplement, you still need to use topical sunscreens as well.
Q: How would you advise to apply sunscreen?
Dr Joe Lewis: The key is you’ve got to put on a lot. When the FDA does a study, they apply about two decilitres per square centimetre which is a really thick layer. It’s been shown that if you reduce that, the reduction effect is exponential.
You put on one quarter of that amount and your benefit is only one-ninth of the original number. Your SPF 33 is only giving you a protection factor of 4.5.
The amount you put on is really critical. So you put enough on so you can just see it, wait about half an hour for cool, dry skin, put another amount on and that second application should be 30 minutes before you actually get your exposure because it needs to have enough time to bind to the stratum corneum and to bind down in the orifice of the follicle. If you put it on when you’re already hot and sweaty, it’s not going to work.
Dr Carl Thornfeldt: I agree with Dr Lewis. Few people apply sunscreen correctly. The average person applies only 25–40% of the recommended amount.
Dr Zein Obagi: You need to wash your face before you apply sunscreen because if your skin is clean and dry, the sunscreen will stay on better. If your skin is oily, you need to eliminate the oil that prevents the sunscreen from sticking to your skin.
As skin produces oil throughout the day, use the astringent from ZO Skin Health TE-Pads. If you have too much oil, you need to wipe the oil off.
Having oil on your face during the day is not disastrous, if you cleanse in the morning and at night. But if you don’t wash the excess oil off at night, that sebum is going to kill your skin.
Dr Joe Lewis: The key for making these product decisions is understanding the physiology of what you’re trying to do. Some of these new advances are intriguing and moving towards good results but the fact is, when we look at percentages of improvement, we’re still in the 80–90% success rate. So why aren’t we at 100%?
No patient ever comes in and wants inadequate results. They want 100% success rate. Getting that rate is dependent on understanding the path of physiology and then modulating all those pathophysiological processes.
Q: Is it better to have an antioxidant in your diet as opposed to applying it topically?
Dr Joe Lewis: All of the above. You need a combination of oral and topical antioxidants.
Dr Zein Obagi: The dietary factor of an antioxidant may play a role, but is so far not proven because all the supplements that people are buying are not regulated. We don’t know if they are absorbed, therefore we don’t have any idea whether they work or not.
So a healthy diet is important—eat many different colours of vegetables, between 20–50 colours if you can, because each one is an antioxidant. But when it comes to delivery to the skin, the brain, the muscles and everything else comes first. Whatever antioxidant is left to reach the skin is not in sufficient quantity which is why I believe that topical application is essential.
Dr Joe Lewis: In our sunscreen study, we didn’t measure the inherent antioxidant content of the skin of the subjects in the study so we just applied topical antioxidants.
We could clearly delineate that the topical application of coffeeberry had a tremendous effect. However, I’m not discounting internal consumption of antioxidants. Obviously you need that.
Dr Zein Obagi: We can’t forget that antioxidants play a role in inflammation. We need to address that. The body is bombarded with chronic inflammation, so a supplement of antioxidants is essential in a healthy diet. But applying antioxidants topically is not going to be sufficient for the body.
Antioxidants have a very short lifespan. Once you apply it to the skin, within about seven to eight minutes it becomes deactivated and is gone. It’s no longer in the skin and it doesn’t go into the cells, so the effect is not helpful for the body.
Dr Joe Lewis: The untreated skin shows the inherent amount of antioxidants that we have. In the study, we saw in all cases a tremendous increase in CPD and 8OG lesions post-UV exposure. After applying the antioxidant, you reduce those lesions so it must be from the topical antioxidant you apply.
The inherent level in the skin is from what you’ve been eating. That is the control; untreated skin. There are huge levels of CPD and 8OG lesions in untreated skin. Maybe these subjects hadn’t eaten any antioxidants, but when we topically applied the antioxidant, we reduced the problem. So the topical application and effect was proven.
Q: In terms of the link between sunscreen usage and vitamin D deficiency, are you making any alterations in your prescriptions?
Dr Carl Thornfeldt: This is a real issue. Dr Pearl Grimes is a leading expert in pigmentary disorders in the US—she spoke to the Academy of Dermatology two years ago about when she developed acute respiratory distress syndrome because her vitamin D levels were very low.
You have to look at vitamin D from two aspects. One, it’s affecting calcium metabolism and the level published in normal range is the effect on calcium. The problem is, for immune benefit and anti-tumour effect, you have to be above the median which in the US labs is around 65 units.
So the goal is not just to get to the bottom of normal range of 30 units, you need to be above the midpoint of about 65 to have the immune benefit and reduction of infection. The key with vitamin D is to get high enough levels.
However, if you look at all the nutrients out there, the number one for nutrient toxicity is vitamin D, in terms of more side-effects, frequency and severity, such as atrial fibrillation, and I often see people sent from a GP who have been given 50,000 units a week but the patient has decided more is better and they’re taking 50,000 units a day. Then they end up ill.
So you have to be very careful. The key is to titrate it so you’re at the mid-level of that range to get the immune benefit.
Dr Beth Briden: Coming from Minnesota—the northern latitude, where we don’t get much sun and a short summer vitamin D deficiency is a concern with using sunscreens—I tell patients to go out in the sun for ten minutes without a sunscreen and then to make sure they apply the sunscreen. Also, if they’re concerned I ask them to have their vitamin D level checked and then get appropriate oral supplementation.
Dr Zein Obagi: I would recommend to patients that while using sunscreen, they should expose their skin to the sun at a good time—like 8 o’clock in the morning—for 15 minutes. One of the studies I have participated in collected data from around the world and found that people who have been exposed to the sun, even in Africa, have low vitamin D levels in their blood. So supplementation of vitamin D is essential, on top of sun exposure.
Q: What are your top three product choices for lightening agents?
Dr Carl Thornfeldt: Epionce Melanolyte Skin Brightening System is my top choice, with MelanoLyte Tx and our new MelanoLyte Pigment Perfecting Serum. Secondly, La Roche Posay Biomedic Pigment Control.
Dr Joe Lewis: My first is methyl gentisate, which is a 1-3 benzoquinone so it’s very similar to hydroquinone but has shown to have no cytotoxic side-effects. Secondly, idebenone—the core of the idebenone molecule is a 1-4 benzoquinone and hydroquinone. It has also a de-pigmenting effect which is not cytotoxic. Finally, CoffeeBerry is full of depigmenting agents like chlorogenic acid, ferulic, caffeic and quinic acid. All three ingredients can be found in Priori and PrioriMD products.
Dr Beth Briden: I still like Tri-Luma. It has been off the market for a few years in the US but it contains a retinoid, 4% hydroquinone and cortisone. In terms of cosmeceuticals, I’ve had excellent results from Enlighten. It’s by NeoStrata and contains 12 botanical lightening agents including chlorogenic acid which inhibits UV induced melanogenesis and a turmeric extract which has been shown to be as effective as 4% hydroquinone without the toxicity. Enlighten inhibits every pathway from the inflammation-causing hyperpigmentation to the tyrosinase-related protein and the packaging of the melanosomes and has been proven to be very effective.
Dr Zein Obagi: ZO Skin Health has Daily Power Defence that includes a highly stable retinol, antioxidants, and DNA repairing enzymes to help minimize UV oxidative damage and uneven pigmentation. If patients use Daily Power Defence on their face every day and at night, as well as the 1% retinol concentration in our ZO Ossential Radical Night Repair Plus, skin will become brighter and have a more even tone and colour.
Q: Which under-eye products would you recommend for dark circles and wrinkles?
Dr Carl Thornfeldt: Epionce Intense Defense Serum provides all the key macro-nutrients and vitamins and nutrients required for the skin for it to function properly. The Epionce Renewal Eye Cream has anti-inflammatory and barrier repair components to it.
Dr Joe Lewis: Any of our Priori eye serums under our HA line. Otherwise, you can apply a little caffeine to reduce the puffiness, a mild AHA because the eye area is delicate and a low concentration of retinol. Ceramides, essential fatty acids and cholesterol are all important in barrier repair.
Dr Beth Briden: I do like the Skin Actives eye cream because it has N-acetyl glucosamine which is the building block of hyaluronic acid and can penetrate the skin.
It also contains the polyhydroxy acids that are non-irritating to further plump the dermis and provide antioxidant/anti-infammatory effects to the skin. Unlike the plain AHA creams, it has caffeine and some optical brighteners to mask the darker circles. It also has a double-blind clinical study that was published showing its effects.
Dr Zein Obagi: My first choice for the eye area is ZO Medical Hydrafirm. It contains antioxidants, shea butter, enzymatic vasodilators, and caffeine. Retinol in low concentrations is useless. You have to go above 0.3 to 0.6 to have an effect.
However, I would not use too much retinol around the eyes. We have a very thin epidermis and once you screw up the barrier function, sensitivity under the eye will create inflammation and make pigmentation worse.
I recommend using antioxidants heavily under the eye and on the face. Within three or four weeks you will see reduction in wrinkles and pigmentation, and you will have a normal-looking lower eyelid.
Dark circles are not only pigmentation. If there is hollowness under the eye, it creates a shadow. It is important not to make that mistake.
If you stretch the skin and see blood vessels under the eye, that also creates darkness under the eye. So you have to address all three elements before you choose a topical agent.
Q: Do you prefer to use alpha hydroxy or polyhydroxy acids? Or beta hydroxy acids?
Dr Beth Briden: I like AHA’s, PHAs and bionic acids better than the beta hydroxyl acids.. Beta hydroxy acids would include salicylic acid which is fairly dehydrating to the skin and it is more irritating. So I would rather go with the alpha and poly hydroxy acids.
Alpha hydroxyl acids provide greater exfoliating effects but, may be irritating to some people with sensitive skin. I like to use them to provide a resurfacing effect to the skin.
The polyhydroxy acids and bionic acids are a great alternative as they are non-irritating and provide gentle exfoliation to restore the skin. They are great for sensitive and dry skin.
Dr Joe Lewis: The absolute AHA of choice is lactic acid. It is the cell signal AHA in the human body.
We have discovered that lactic acid binds to the CD44 glycoprotein on the cell membrane in the fibroblast and sends the message that says we need to make hyaluronic acid. Hyaluronic acid is the natural moisture retention substance in the epidermis and dermis and you need lots of it.
You get great moisture retention and that’s how you plump out the lines and wrinkles. Lactic acid does this better than any other AHA.
Dr Carl Thornfeldt: I agree with Dr Lewis. The activity of the lactic acid is very potent. Others that we’ve found that are very effective are malic acid and the BHA salicylates. The salicylates can be formed to have increased activity with decreased irritation.
We conducted research into the salicylates, combining salicylic acid with linoleate and a key signalling ion for barrier function—we had much faster and better penetration and produced a better cosmetic result.
In the double-blind prospective controlled trials combined with anti-inflammatory barrier repairing Epionce Renewal Facial Cream, this combination was statistically superior to the Renova which is emollient Tretinoin 0.05% cream in reversing photoageing.