Summary

There is a demand for compounded pharmaceuticals in dermatology because they can offer medications for patients that are not commercially available. Dermatologists’ skincare products or cosmeceuticals can be cleansers, toners, moisturizers, serums, and masques that hold active ingredients such as retinoids, alpha-hydroxy acids, polyhydroxy acids, skin lightening, antiacne, growth factors, peptides, and vitamins. Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. Instituting the correct routine will slow the progression of aging and work towards reversing the extrinsic and intrinsic aging changes. In aesthetic practice, using cosmeceuticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications. Patients with conditions such as rosacea, eczema, seborrhea, and acne require specially selected products that will enhance skin appearance without irritating their underlying conditions.

Dermatologists’ skincare products or cosmeceuticals are topically applied products, such as creams, lotions, and ointments, that are not merely cosmetics that make more beautiful camouflage yet are not natural drugs that have undergone rigorous controlled studies. This continues to be an area of new product development. Aesthetic patients are calculating about skincare and often seek professional advice when choosing cosmeceuticals. Cosmeceuticals are moisturizers, serums, and masques with active ingredients that confer added skin benefits. In aesthetic practice, the use of cosmeceu­ticals in combination with cosmetic procedures is a new treatment ideal for skin rejuvenation. Developing individualized skincare products requires a basic understanding of cosmeceuti­cal ingredients. Patients with rosacea, eczema, seborrhea, and acne require specially selected products that will enhance skin appearance without irritating their underlying conditions. Pre-treatment with cosmeceuticals can prime the skin for procedures, and post-treatment can reduce complications. Thus, understanding the benefits of cosmeceutical ingredi­ents is essential in the clinical setting. Medically based skincare products target three cellular components that contribute to aged skin: keratinocytes, melanocytes, and fibroblasts. Instituting the correct routine will slow the progression of aging and work towards reversing the extrinsic and intrinsic aging changes. The goals of the topical regimen are to reverse sun damage, slow the aging process by increasing collagen, elastin, and glycos­aminoglycans (GAGs), minimize oxidative damage, and address some active disease states (acne, rosacea, melasma).

Retinoids

Topical synthetic retinoids can be viewed as the “workhorse” of any skincare product. There are three generations of synthetic retinoids. The first generation includes tretinoin and isotretinoin; the second-generation retinoids include acitretin and etretinate. Among the third-generation retinoids are adapalene, bexarotene, and tazarotene. Tretinoin has the most extended safety and efficacy record in skin rejuvenation. Multiple studies have proved the efficacy in treating wrinkles, reducing pigmentation, acne scarring, and antibacterial activity against Propionibacterium acnes and staphylococcus spp. These retinoids have also been combined with other agents such as hyaluronic acid and glycolic acid to improve the treatment of wrinkles and scarring. There are a variety of ‘Cosmeceuticals’ that use topical retinoids in their products. Most topical retinoids used in cosmetic products are precursors to retinoic acid.

Alpha-hydroxy acids (AHAs) and Polyhydroxy acids (PHAs)

AHAs have been used for centuries as exfoliating agents. They are a family of acids derived from milk or fruits: lactic acid (milk), glycolic acid (sugar cane), malic acid (apples), citric acid (citrus fruits), and tartaric acid (grapes). They create a smooth feel to the skin by breaking up keratinocyte adhesion in the stratum corneum and the upper epidermis. This is also how they exert their beneficial effects on acne. Furthermore, disrupting the stratum corneum allows other skin products to penetrate more deeply when applied to the skin. Ongoing studies on AHAs demonstrate that their benefits extend far beyond exfoliation. AHAs increase glycosaminoglycan and collagen production and improve the quality of elastic fibers. AHAs also reduce pigment clumping in the epidermis, making them effective skin Lighteners. Although AHAs are incredibly beneficial anti-aging ingredients, side effects such as stinging and burning limit their use in some patients. To overcome stinging, poly­hydroxy acids, including gluconolactone and bionic acids, were devel­oped. Gluconolactone has been used to treat rosacea patients sensitive to alpha-hydroxy. As an added benefit, polyhydroxy and supernatural acids are also antioxidants.

Skin-Lightening Agents

Hyperpigmentation is one of the most common disorders for which patients seek treatment. The cause can range from sun damage, melasma, ethnic predilection (under eyes), and post-inflammatory hyperpigmentation (PIH). Hydroquinone (HQ) has been used for over 40 years to treat hyperpigmentation. Over-the-counter products have 1–2% HQ, whereas preparation con­centrations can be as high as 10%. We combine HQ with other agents that either enhance its penetration (AHA, retinol) or are synergistic in their skin-lightening effects (vitamin C, topical steroids). While I can use it to treat focal areas, it is often best to apply this agent to the whole face and apply a more significant amount over the darkest regions. This helps prevent a bleaching complexion. I should reassure patients that contrary to popular opinion, hydroquinone does not bleach the skin but restores the skin to the patient’s baseline skin color.

Licorice extract comes from the root of Glycyrrhiza glabra. It holds glabridin (a tyrosinase inhibitor) and liquitin. Studies on licorice extract have shown that it can reduce ultraviolet B (UVB) pigmentation and has some antioxidant properties. Arbutin is a naturally occurring derivative of HQ found in bearberry. Kojic acid, a chelation agent produced by several species of fungi, is a byproduct of the malted rice fermentation used to manufacture sake. Azelaic acid is another skin-lightening agent, which works via the inhibi­tion of tyrosinase. In addition to its effects on pigmentation, azelaic acid is efficient in treating patients with acne and rosacea. Antioxidants are believed to minimize free radical damage, which has been associated with the processes of photoaging and carci­nogenesis. Photodam­aged and aged skin show a marked decrease in the expression of L-ascorbic acid. Vitamin C (ascorbic acid), vitamin E (alpha-tocopherol), and other polyphenols have become popular within the cosmeceutical industry as the understanding of free radical damage grows.

Vitamin C, or L-ascorbic acid, is a water-soluble antioxidant popular cosmeceutical ingredient. Before UV exposure, the topical application of vitamin C confers photoprotection against sunburn and UV-induced immunosuppression. In addition, vitamin C acts as a cofactor for enzymes responsible for collagen synthesis. Vitamin C inhibits tyrosinase and reduces melanin, making it an active skin-lightening agent. Vitamin C is an active anti-inflammatory compound and has been evaluated in the post-procedure setting. Products containing vitamin C in combination with other antioxidants have been shown to provide added benefits compared with vitamin C alone. A formulation having vitamin C, E, and the botanical antioxidant ferulic acid supplied eight times the photo­protection of vitamin C alone. Combination anti­oxidants have also been looked at in the post=procedure setting. Vitamin E is a lipid-soluble antioxidant responsible for the protection of membranes. There is an ongoing debate over the possible role of vitamin E in skin cancer prevention. Collagen stimulation and the slowing of the aging process are the goals with newer generation topical agents, including peptides, cytokines, and growth factors. Niacinamide or vitamin B3 readily penetrates human skin, reducing skin redness, improving sallowness, and lightening hyper-pigmentation. Topical application of niacinamide enhances skin barrier lipids and enhances barrier function. It also reduces sebum production and pore size, making it an excellent choice for patients with oily skin who desire rejuvenation. Niacinamide increases collagen and glycosaminoglycan production, boosting dermal matrix components that can smooth wrinkles.

Botanical extracts are found in many cosmeceuticals for­mulations. Extracts of green tea, grape seed, resveratrol, pine bark, pomegranate, and Coffea arabica are most popular. Botanical extracts contain various phenolic and polyphenolic antioxidants that neutralize free radicals and increase collagen production. Polyphenols inhibit protein glycation, which contributes to the wrinkling and sallowness seen in sun-damaged patients. They also act as anti-inflammatory compounds. Polyphenols confer photoprotection and prevent skin cancers. Botanical extracts topically applied lightening pigmentation, improving lines and wrinkles, and reducing skin redness.

Bioactive peptides were first found through the study of wound healing. Antimicrobial peptides act as part of our innate host defense against pathogens and are essential for wound healing. The second type of peptide important in wound healing is derived from the breakdown of proteins such as collagen and elastin. These small peptide fragments are produced when the skin is injured or inflamed to stimulate the synthesis of dermal matrix components such as collagen and glycosaminoglycans. Peptides that inhibit neurotransmitter release are found in cosmeceuticals claiming to have Botox-like effects.

Growth factors and cytokines regulate a variety of pathways important in skin aging. The use of growth factors for skin rejuvenation is supported by the fact that suppression of transforming growth factor-beta by UV ­induced oxidative stress results in overexpression of metalloproteinases and a reduction in collagen production. Clinical studies have confirmed that consistent use of cosmeceuticals holding growth factors and cytokines improves skin wrinkling. Several cosmeceuticals contain human growth factors and cytokines harvested from fetal fibroblasts. Additionally, plants and animal growth factors are marketed as skin rejuvenating compounds. The topical application of growth factors is limited because human growth factors are hydrophilic and have a significant molecular weight that prevents them from penetrating the epidermis. Some have suggested that alternative routes to the dermis might include hair follicle penetration. In aesthetic practice, topical growth factors have gained popularity as an adjunct treatment for patients undergoing laser resurfacing, as they are known to be important in wound healing.

There is a demand for compounded pharmaceuticals in dermatology because they may offer medications for patients that are not commercially available, prof Moawad said. High-skilled pharmacists prepare our compounded medications specially trained to meet these individual patient needs. This professional relationship between (1) Our patient, (2) Our pharmacist, and (3) Prof. Moawad is known as the ‘compounding triad,’ and each person must interact with the other two individuals to supply safe and cost-effective compounded medications and cosmeceuticals.

The topical application of pharmaceutical agents is a fundamental principle of dermatological therapy. However, the valuable barrier function of the skin significantly impairs the bioavailability of most topical drugs. Many pharmaceutical substances are too hydrophilic or too large (> 500 kDa) to permeate the stratum corneum at relevant concentrations, and therefore must be encapsulated in liposomes, injected, or administered systemically. Apart from a chemical modification of active substances or their vehicles, transdermal delivery of external chemicals has been aided by physical methods such as microneedles, iontophoresis and electro-osmosis, electroporation, and laser, radiofrequency, and ultrasound. The local increase in temperature increases blood flow, and in turn, the rate of permeation/transport of active substances into the skin increases. This technique has the advantage of not employing a chemical, is non-invasive, and does not require activation of self-repair mechanism by the skin. Microneedle treatment is inexpensive and straightforward, and the skin barrier disruption it causes resolves quickly. Therefore, it can serve as an effective physical method of enhancing transdermal delivery of medications to treat many cosmetic and dermatological conditions.

Abrasion techniques involve the direct removal or disruption of the upper layers of the skin to facilitate the permeation of topically applied medicaments. Some of these devices are based on techniques used by dermatologists for superficial peel resurfacing (e.g., microdermabrasion) in the treatment of acne, scars, hyper-pigmentation, and other skin blemishes.  The physicochemical properties of the drug do not restrict the delivery potential of skin abrasion techniques. Application of skincare products post-MDA therapy may be promising to improve their dermal uptake.

Multiple lasers have been used to improve skin penetration for drugs.  Laser modalities include ablative skin resurfacing (ASR), nonablative dermal remodeling (NDR), and fractional photo-thermolysis (FP). Laser treatment is often used for dermatological conditions such as acne and confer “facial rejuvenation,” where the laser radiation destroys the target cells over a short frame of time (∼300 ns). Direct and controlled exposure of a laser to the skin results in the ablation of the SC without significantly damaging the underlying epidermis. Removal of the SC via this method has been shown to enhance the delivery of lipophilic and hydrophilic drugs. Fractional ablative lasers are an innovative strategy to overcome the epidermal barrier in a standardized, contact-free manner. The bioavailability of topical agents can be significantly enhanced using laser-assisted drug delivery (LADD).

Ablative fraction radiofrequency (AFR)-assisted drug delivery is a promising tool for the future of dermatology. We expect to see several agents to be paired with AFR for enhanced drug delivery. Radiofrequency thermal ablation has been used highly for electrosurgery and ablation of malignant tissues. This involves exposure of skin to high-frequency alternating current (∼100kHz) and results in the formation of heat-induced microchannels in the membrane, like when laser radiation is employed — radiofrequency-induced microchannels are staying open for less than 24 h.

Ultrasound involves ultrasonic energy to enhance the transdermal delivery of solutes either simultaneously or via pre-treatment and is often referred to as sonophoresis or phonophoresis.  Ultrasound has been shown to enhance transdermal transport of low molecular weight drugs (<500 Daltons) across human skin. Higher transdermal transport by this method is attributed to cavitation induced either inside or outside the skin. In addition, oscillations of cavitation bubbles result in significant water permeation into disordered lipid regions and lead to the formation of aqueous channels in the intercellular lipids of the stratum corneum. Ultrasound parameters such as treatment duration, intensity, and frequency are all known to affect percutaneous absorption, with the rate being the most important.  Although frequencies between 20 kHz–16 MHz have been reported to enhance skin permeation, frequencies at the lower end of this range (<100 kHz) are believed to have a more significant effect on transdermal drug delivery macromolecules of molecular weight up to 48 kDa. The proposed mechanism behind the increase in skin permeability is attributed to the formation of gaseous cavities within the intercellular lipids on exposure to ultrasound resulting in disruption of the SC.

No Needle Mesotherapy or Electroporation

No-needle mesotherapy device seeks to do the same aim as injection mesotherapy. Thus, it is targeted at the same treatment indications, such as skin rehydration and toning, whitening, acne and cellulite, and fat reduction treatments. It uses a low pulsed frequency electric current to deliver active ingredients into the skin. Treatments are said to feel like a ‘pins and needles’ sensation but are generally described as not uncomfortable. Mesotherapy is a medical technique first devised in the 1950s by a Frenchman called Dr. Michel Pistor. It involves the micro-injection of a specially prepared mixture of vitamins, amino acids, and medications placed into the mesoderm (i.e., just millimeters under the skin) within a problematic area. It was initially used to treat such conditions as rheumatism, sports injuries, and for the improvement of blood circulation, and has now been used successfully by some practitioners for the treatment of cosmetic conditions, including skin rejuvenation, hair re-growth, localized fat reduction, and as a treatment for cellulite. Many people are not comfortable with the concept of multiple injections, so aesthetic device manufacturers have sought ways to offer no-needle alternatives. If you are considering treatment with no-needle mesotherapy, the following information will give you a basic understanding of the procedure. It can’t answer all your questions since a lot depends on the individual patient.

The art of skin rejuvenation is in taking a personalized approach to each patient so that the skincare regimen is easy to use, tackles their presenting complaints, and gives visible results. Additionally, it is vital to guide patients through the steps that their skin will go through as it acclimates to the skincare product. Skincare routines must be tailored to the patient’s desires, the speed by which they want to see improvement, and their work/lifestyle. If patients would like to see results quickly and can tolerate redness, peeling, and flaking, a more aggressive product is prescribed. This is also the case if we are quickly preparing the skin for surgery or resurfacing. Furthermore, patients with melasma are encouraged to pursue an aggressive skincare product whenever possible, so that results are achieved before the skin builds a tolerance to the topical agents. However, if the patient is prone to quitting and not tolerating dryness, then a milder product is implemented. For all the rest, a moderate approach is taken. A medical approach to skincare is one in which a thoughtful, personalized product is formulated for each patient in a manner that addresses the function of the cells of the skin. The skincare routine can be used to prepare a patient’s skin for resurfacing, address inflammatory conditions such as acne and rosacea, and enhance the results of surgical procedures. Additionally, as the passage of time continues, and the aging process begins to undo the effects of surgery, the skin can be kept vibrant and glowing with the proper topical agents. This further prolongs the results of the surgical procedure.

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