Key Words: cosmetics, photoprotection, SPF, sun protection factor, sunscreen, UV, ultraviolet light

Sunscreens are perceived as gooey, sticky, uncomfortable products that are difficult to apply and distasteful to wear. This accounts for dismal compliance when dermatologists ask patients to use daily sunscreen. Since the time delay between accumulated sun exposure and skin cancer can be more than 20 years, patients do not receive a short-term benefit from photoprotection. Any marketing genius will tell you that compliance requires both self-perceived short- and long-term benefits in order to reinforce positive behavior. This insight into the human psyche led skin care companies to develop the concept of the “multifunctional cosmetic,” which by definition delivers several benefits in one bottle. Currently, popular multifunctional cosmetics include sunscreen-containing moisturizers and facial foundations.

Sunscreen-containing Moisturizers

Sunscreen-containing moisturizers have dramatically improved photoprotection compliance. These products can provide moisturization by decreasing transepidermal water loss through creation of an environment that is optimal for barrier repair. Through the use of occlusive agents such as dimethicone, petrolatum, and mineral oil, as well as the use of humectants such as glycerin, propylene glycol, and hyaluronic acid, a therapeutic moisturizer can aid in the restoration of the corneocyte and intercellular lipid organization. In addition, a sunscreencontaining moisturizer can deliver effective ultraviolet B (UVB) and ultraviolet A (UVA) photoprotection, thereby contributing to the prevention of sunburn, photoaging, and skin cancer simultaneously. Through the inclusion of active ingredients such as retinol, niacinamide, and/or green tea, additional antiaging benefits may be achieved. In short, one bottle of sunscreencontaining moisturizer can be designed to moisturize the skin, repair the barrier, stop sunburn, prevent skin cancer, minimize photoaging, and potentially reverse oxidative insults.

Most sunscreen-containing moisturizers are formulated at a sun protection factor (SPF) between 15 to 30. SPF 15 products can be designed with little UVA photoprotection and they may or may not be labeled as broad spectrum. SPF 30 products must contain both UVB and UVA photoprotective ingredients and are therefore preferred. This logic encouraged the American Academy of Dermatology to restate its sun protective recommendations and raise the minimum recommended SPF to 30. For most formulations, SPF 30 is a nice compromise between photoprotection and aesthetics. Once the SPF raises much above 30, the product becomes sticky. Many highly effective sunscreen filters, such as octocrylene, are thick oils and increasing their concentration in the final formulation leads to poor aesthetics.¹ Yet, for casual limited sun exposure, SPF 30 provides excellent daily photoprotection.²

Sunscreen-containing Facial Foundations

If a sunscreen-containing moisturizer is tinted to match the skin, it can then be classified as a facial foundation. Facial foundations are another category of multifunctional cosmetics that can be helpful in encouraging sun protection compliance. There are four basic facial foundation formulations: oil-based, water-based, oilfree, and water-free forms. The most popular facial foundations are liquid oil-in-water emulsions containing a small amount of oil in which the pigment is emulsified with a relatively large quantity of water. The primary emulsifier is usually a soap, such as triethanolamine or a nonionic surfactant. The secondary emulsifier, present in smaller quantity, is usually glyceryl stearate or propylene glycol stearate.

Facial foundations are designed to color, blend, and camouflage the underlying skin and create an illusion of perfect complexion beauty. The ability of a foundation to conceal or cover the underlying skin is known as “coverage.” Higher coverage products deliver better photoprotection while lower coverage products deliver less photoprotection. In this case, the photoprotection is due to inorganic filters in the formulation, which commonly include titanium dioxide, zinc oxide, talc, kaolin and precipitated chalk. Even coloring agents, such as iron oxide, can function as inorganic filters.

Sheer coverage foundations with minimal titanium dioxide are almost transparent and have an SPF around 2 while moderate coverage foundations are translucent and have an approximate SPF of 4 to 5. Thick, waterproof cream facial foundations that are used for camouflage purposes or post-surgically completely obscure the underlying skin and have an unlimited SPF because they function as a total physical block. For persons with severe photosensitive facial skin disease, such as lupus, these waterproof cream facial foundations offer superior photoprotection.

In addition to the normal photoprotective constituents of a facial foundation, other inorganic and organic filters can also be added. The most commonly added organic filter is octyl methoxycinnamate. It is an excellent UVB filter with no aesthetic issues and limited allergenicity.¹ It may be combined with other filters, such as oxybenzone, to increase coverage in the UVA range.^3,4 Some of the newer facial foundations even add avobenzone that has been photostabilized with octocrylene and oxybenzone. Selecting the proper mixture of sunscreen ingredients is key to providing superior photoprotection and aesthetics while offering a high broad spectrum SPF.

New sunscreen-containing facial foundation formulations are available in a variety of forms: liquid, mousse, water-containing cream, soufflé, anhydrous cream, stick, cake, and shake lotion. Liquid formulations are most popular because they are the easiest to apply, provide sheer to moderate coverage, and create a natural appearance. As previously mentioned, they contain mainly water, oils, and titanium dioxide. To this basic formulation, sunscreen filters can be added. For most patients, this type of sun protection through a facial cosmetic is the best way to increase compliance.

Other formulations of facial foundations can also be created. If the liquid is aerosolized, a foam foundation known as a mousse is produced. A cream foundation has the additional ingredient of wax, which makes a thicker, occlusive, more moisturizing formula. These thicker cream facial foundations also deposit more pigment on the skin surface and obscure more of the underlying skin. Cream formulations typically offer better photoprotection than liquids. Whipping the cream produces a soufflé foundation. Finally, an anhydrous cream with no water in its formulation provides enhanced occlusion and exceptional long-lasting coverage. These products resist water removal better and can be used with greater success in persons who need superior photoprotection when perspiring heavily.

There are three final forms of facial foundation that have been adapted for sun protection. These include stick, cake, and powder facial foundations. Adding more wax to the cream facial foundation results in a stick that can be stroked across the face. These facial foundation sticks are also water-free and provide water resistant photoprotection. This is in contrast to the cake and powder facial foundations that are dusted over the face. A cake foundation is a compressed powder consisting of talc, kaolin, precipitated chalk, zinc oxide, and titanium dioxide compressed into a cake that is applied to the skin with a sponge. If the ingredients are not compressed into a cake, they can be left loose in a jar with a brush attached to one end. This loose powder facial foundation is sometimes called a mineral makeup.

Mineral makeup are some of the newest sun protective cosmetics. They are dusted onto the face and can be just easily dusted off the face. Powders do not provide water resistance characteristics, making them only appropriate for day wear with casual sun exposure. Also, the powder does not provide an even film over the face, allowing for uneven photoprotection. For the patient with serious sun protection needs, it is best to apply a sunscreencontaining moisturizer followed by a mineral makeup. The moisturizer will allow the powder to stay in place and offer increased photoprotection due to layering. It is important to note that the SPF rating of the powder and the moisturizer are not additive. For example, an SPF 15 sunscreen-containing moisturizer and an SPF 15 mineral makeup do not combine to confer SPF 30 photoprotection. Each product application will make a more even sun protective film, allowing closer approximation of the SPF 15 rating.

Multifunctional SPF Rated Cosmetics

Multifunctional SPF rated cosmetics are increasing in the marketplace. Lipsticks, lip balms, facial serums, and eye creams are all commercially available formulations that can possess an SPF rating. Increasing patient compliance with sun protection through the inclusion of sunscreen filters in many commonly used facial products can be a synergistic effect. Patients do not wish to purchase or use multiple products that are expensive and time consuming to apply. The multifunctional cosmetic is an important dermatologic advance. This trend is expected to continue with extensions to male skin care, such as sunscreencontaining after shave preparations. Sunscreen filters are also finding their way into hair care products that claim to prevent color fading. Protection from UV exposure improves color purity and retention, lengthening the time a hair dye can be worn until repeat dyeing is required.⁵ This is a positive trend for dermatology as it reinforces our safe sun message to our patients.

Conclusion

With the widespread emergence of sunscreen-containing moisturizers, foundations, and various lip treatments, it is apparent that the cosmeceutical industry has embraced the importance of photoprotection. These multifunctional products have the potential to encourage patient adherence to regimented sunscreen use by facilitating ease of application, thus minimizing the need for any significant behavioral modification, particularly during the morning routine.

References

1. Draelos ZD. Photoprotection in colored cosmetics. In: Lim HW, Draelos ZD (eds). Clinical guide to sunscreens and photoprotection. New York: Informa Healthcare USA, (2008).
2. Draelos ZD. Sunscreens and hair photoprotection. Dermatol Clin 24(1): 81-4 (2006 Jan).
3. Steinberg D. Regulatory review: sunscreens. Cosmet Toiletries 121(11):41-6 (2006 Nov).
4. Caswell M. Sunscreen formulation and testing. Cosmet Toiletries 119(9):49-58 (2001 Sep).
5. Wakefield G, Stott J, Duggan A. UVA skin protection: issues and new developments. Cosmet Toiletries 122(2):57-62 (2007 Feb).

Dermatology Consulting Services, High Point, NC, USA
Department of Dermatology, Wake Forest University, Winston-Salem, NC, USA

ABSTRACT

The in-office dispensing of topical skin care products by dermatologists is a source of frequent debate. Guidelines for proper dispensing have been penned by various medical organizations, yet the controversy continues. With the increasing number of physician-dispensed lines available for sale, combined with mounting medical financial issues, the ongoing debate surrounding inoffice dispensing will continue.

Key Words:
Physician dispensing, guidelines, ethics

One of the hottest current debates in dermatology surrounds the premise that dispensing provides a valuable service to patients,^1-3 while opponents argue that dispensing is only a source of physician profit.^4,5 Most states do not allow the dispensing of prescription pharmaceuticals, which means only over-the-counter (OTC) skin care products can be directly sold to patients. This includes moisturizers, sunscreens, serums, toners, cleansers, vitamins, colored cosmetics, OTC acne formulations, hair care products, and nail adornments, to name a few. In short, anything sold in a mass market retailer, such as Wal- Mart^© or Target, can be sold by a physician as long as that physician holds a business license and pays the appropriate sales tax. No one would argue that it is unethical for these products to be sold to consumers, but the situation may be different when it involves a doctor-patient relationship. Perhaps this issue deserves further consideration.

Professionalism

The first point of controversy surrounds the issue of professionalism. Physicians are classified as professionals, meaning that they give advice and make decisions from a selfless perspective. The patient seeks this advice because he or she feels that the physician will put aside personal financial gain and treat the patient in the best manner possible. The sale of office-dispensed products tests this premise. The dispensing physician may argue that the best product to improve the patient’s skin can only be found in a product sold from their office. This means that the opportunity to purchase such a product can provide the patient with enhanced care and allows the physician to offer a valuable service. In addition, some proponents suggest that on-site purchases can save time and allow the patient to get a recommendation and product simultaneously. However, other physicians contend that the practice may promote unprofessional or unethical conduct when a retail component is
incorporated into a clinic setting. Certainly, there are two perspectives to this argument.

The key to finding the truth in this controversy is to analyze the value of products sold in a physician’s office. Is there any topical OTC product that is so unique in a physician-dispensed line that it could not be obtained in the mass market? Is there any ingredient available in a physician-dispensed line that must be used over all other similarly functioning ingredients available in mass market retailers? Is the physician providing something important or a biased recommendation? This is the key ethical question that all dispensing physicians must
critically ask themselves.

The Price of In-Office Dispensed Products

The second point of controversy involves the price of inoffice dispensed products. Most manufacturers of these lines recommend that physicians double the wholesale price to obtain the retail price. This may appear to be only a 100% mark up, but in actuality, it is much more. The manufacturer has already taken a 200%-500% profit margin to arrive at the wholesale price, which means that the physician in selling a product to the patient at 300%-600% above its cost. Certainly, a profit must be made on the sale of any OTC formulation, but the key ethical question is how much profit can be justified.

The Efficacy of In-Office Dispensed Lines

The third point of controversy is the efficacy of inoffice dispensed lines. Most dispensed products are designed to function in the personal hygiene or antiaging realm, not the pharmaceutical realm. This means that product expectations are reduced while product safety is increased. Dispensed lines are not intended to replace prescription therapies, but rather to enhance their efficacy. This may be the case with dispensed acne treatment products containing benzoyl peroxide that are combined with topical prescription retinoids and antibiotics to deliver control of noninflammatory acne lesions. Perhaps dispensed anti-aging creams might increase the tolerability of tretinoin, but what else can they offer? Does the topical botanical cocktail really deliver something beneficial to the skin that can be medically documented by the physician? It is this evidence-based approach to office dispensed products that is lacking in some instances, depending on the research efforts of the product line manufacturer. Compatibility is called into question when uniting the science of pharmaceuticals with their certainty of efficacy and the puffery of claims associated with some anti-aging creams.

The Meaning of the Physician-Businessperson

The prior discussion leads to our fourth issue, which is the meaning of the physician businessperson. Is it possible to be a physician-businessperson or is this phrase an oxymoron? In the US, a modern business model for some entrepreneurial physicians is labeled the medispa. Physicians operating medispas come from no particular background and may be dermatologists, plastic surgeons, family practitioners, internists, gynecologists, etc. They supervise the treatments provided by a staff of nurses and aestheticians including body massages, laser hair removal, cellulite wraps, manicures, botulinum toxin injections, intense pulsed light facial peels, and hyaluronic acid filler injections, to name a few. The business concept seems to combine the minimally risky aesthetic medical procedures with the relaxation and adornment practices learned in cosmetology school. These establishments frequently sell physician dispensed product lines as an additional source of income. These products are recommended by the aestheticians and nurses that provide the services and not by the supervising physician, who does not see every client. If the recommendation to purchase from an in-office dispensed line does not come directly from the physician, does the product purchase carry the same value? Is it a medical service or a business venture similar to a cosmetic counter at a department store? Is the physician functioning in a medical realm or a business realm?

Patient Evaluation of the Products

The final point of controversy is the ability of the patient to objectively evaluate product purchases. This may be difficult when the patient feels compelled to listen to the sales pitch of an aggressive aesthetician or is directed to walk by the sales counter when exiting the medical office. The patient may conceive that products must be purchased in order to continue a favorable patientphysician relationship, or to receive medical care in the office. A patient in a medical office is a captive audience and this situation must not be abused. The patient should have the option to discuss product sales or opt out of the conversation when checking in to a medical office. Perhaps this discussion should take place at the front desk. Patients could be asked about product sales and their wishes obeyed.

Guidelines

Many professional organizations, such as the American Medical Association and the American Academy of Dermatology, have weighed in with opinions regarding the practice of office dispensing.^6,7 While the wording and details vary from organization to organization, the basic spirit of the recommendations are to preserve medical ethics. Indeed, this is key. However, there is no agreement among physicians as to what constitutes ethical dispensing. Thus far, this discussion has perhaps raised more questions than it has answered. Only through this type of soul searching can the true value of in-office dispensing be determined.

Conclusions

Moving forward, it would seem that many issues could be resolved by developing a physician board that would approve products for in-office dispensing, much like the US FDA provides approval for pharmaceuticals. This board could evaluate the efficacy of skin care lines manufactured for in-office dispensing that is based on research provided by the manufacturer. Performance guidelines could be established requiring rigid scientific studies to meet predetermined endpoints. Only dispensed lines that meet these requirements would be certified for in-office sales. This type of certification would raise the bar on product performance and perhaps offer something truly unique in skin care. Perhaps a proposal such as this could quell the controversy regarding physician dispensing.

References

1. Farris PK. Office dispensing: a responsible approach. Semin Cutan Med Surg 19(3):195-200 (2000 Sep).
2. Higham R. Integration of moisturizers and cleansers into a busy dermatology practice. Cutis 76(6 suppl):32-3 (2005 Dec).
3. Nestor MS. Dermatology practice management enhancement: implications for dermatology in the age of managed care. Semin Cutan Med Surg 19(3):163-9 (2000 Sep).
4. Miller RC. Dermatologists should guard their patients’ purse, not pick their pockets! Arch Dermatol 135(3):255-6 (1999 Mar)
5. Epstein E. Are we consultants or peddlers? Arch Dermatol 134(4):508-9 (1998 Apr).
6. AMA Council on Ethical and Judicial Affairs. Sale of health-related goods from physicians’ offices. CEJA Opinion 8.063 issued December 1999 and adopted June 1999.
7. AAD Position Statement on Dispensing. Approved October 1998 and amended September 1999.

The American Academy of Dermatology’s
Position Statement on Dispensing

(Approved by the Board of Directors October 12, 1998; Amended by the Board of Directors September 26, 1999)
Reprinted with permission from The American Academy of Dermatology

Dermatologists should not dispense or supply drugs, remedies or appliances unless it is manifestly in the best interest of their patients.

Dermatologists who dispense in office should do so in a manner with the best interest of their patient as their highest priority, as it is in all other aspects of dermatologic practice.

It is ethical to dispense, by sale, prescription or non-prescription drugs, to patients in a dermatologist’s office except in the following circumstances:

1. When the dermatologist places his/her own financial interests above the welfare of his/her patients.
2. When creating an atmosphere which is coercive to patients such that they feel compelled to purchase drugs from the dermatologist.
3. When dispensing drugs under a dermatologist’s private label without clearly listing the ingredients, including generic names of the drugs.
4. When dispensing to patients drugs which are easily available at proprietary pharmacies without advising patients of this availability.
5. When representing drugs as being a special formula not elsewhere available, when that is not the case.
6. When selling health-related products whose claims of benefit lack validity.
7. When refusing to give refills of drugs except that they be purchased from the dermatologist.
8. When charging patients at an excessive mark-up rate.

Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, and Dermatology Consulting Services, High Point, North Carolina, USA

ABSTRACT
Photoaging is a multisystem degenerative process that involves the skin and the skin support systems, including the bone, cartilage, and subcutaneous compartments. These structures provide the architectural support for the dermis, epidermis, and stratum corneum. A multiprong approach to photoaging involves reversing the undesirable changes in each of these structures. Dermatologists should become adept at treating all of the visible manifestations of photoaging.

Key Words:
photoaging, multiprong approach

Photoaging is a multisystem degenerative process that involves the skin and the skin support systems, including the bone, cartilage, and subcutaneous compartments. These structures provide the architectural support for the dermis, epidermis, and stratum corneum. A multiprong approach to photoaging involves reversing the undesirable changes in each of these structures. Dermatologists should become adept at treating all of the visible manifestations of photoaging.

Dermatologic Approach to Facial Rejuvenation

The compartments of the face that require attention include:

• Bony architecture
• Cartilage architecture
• Subcutaneous compartment
• Viable dermis and epidermis
• Nonviable epidermis
• Stratum corneum

Bony Architecture

One of the most important areas for consideration is the bony architecture over which the skin lies. Without a strong framework, the skin hangs formless over the face. Bone demineralization begins earlier than thought, at around age 25 in fair-complected females. It is this bone loss that leads to dulling of the facial features.

Unfortunately, published results outlining the risks and benefits of hormone replacement therapy¹ lead many women to discontinue estrogen supplementation due to concerns about coronary disease; however, bone replacement therapy, such as bisphosphonates, is usually not begun until overt evidence of osteoporosis is present. Furthermore, many fair-complected women are Vitamin D deficient according to the new revised laboratory normal values.² Dermatologists should become proficient at advising patients regarding facial bone health.

Instituting therapy for anticipated or existing osteopenia or osteoporosis is not difficult. Women who are at risk for facial bone loss should probably have a hip or spine Dexascan yearly to chart the success of therapy. Vitamin D therapy should be initiated at 50,000 IU for 2 weeks followed by 800 IU daily as a nutraceutical. Calcium carbonate should be given as a supplement at 1gm daily accompanied by a bisphosphonate administered once weekly. At least 30 minutes of weight-bearing exercise should be undertaken 3 times weekly. Patients should be reminded that swimming and cycling do not constitute weight-bearing exercise.

Cartilage Architecture

The architecture of the cartilage of the face, in addition to the bony architecture, defines the shape of the face. The most important facial structure dependent on cartilage is the nose. The cartilage does not disappear with advancing age, but does change shape.

Much of the change occurs during pregnancy due to the relaxins that are secreted at high levels during the final trimester to allow childbirth. I believe these relaxins also cause the tip of the nose to droop, which contributes to a more mature appearance of the female face. At present, there is no research regarding the preservation of the youthful nasal shape during pregnancy. Perhaps the use of hyaluronic acid fillers during pregnancy could preserve the up-turned, youthful female nose.

Subcutaneous Compartment

The subcutaneous compartment undergoes much of the change that contributes to the aged appearance of the face. It is presently unclear why subcutaneous fat from all over the body is removed, including the facial fat, and redeposited intrabdominally. Some researchers who study anti-aging have advocated the notion that these changes are due to lower growth hormone levels and recommended supplementation.³ This recommendation is certainly outside current mainstream medicine. Others point to the fat redistribution on the body that occurs with menopause.^4,5 In postmenopausal women fat is typically redistributed to the breast, arms, waist, thighs, and buttock with loss of facial fat.

At present, the best way to replace large amounts of fat that are lost from the face, resulting in prominent nasolabial and melolabial folds, is through autologous fat transfer. The fat is removed from the hips or thighs and moved to the face for insertion on the bone, in the muscle, and below the skin. This dermatologic technique can result in a more youthful appearance without the downtime and scarring of a face-lift. I believe that autologous fat transfer is preferable to a face-lift because it does not change the essence of the individual’s face. Many women lose their characteristic appearance after a face-lift because the skin has been stretched and repositioned over the fat-devoid bones creating an angular, gaunt appearance. Although the skin folds have been removed, the youthful curves of the face have not been recreated.

Viable Epidermis and Dermis

The viable epidermis and dermis are the essence of the skin. It is the loss of dermal collagen that leads to wrinkling and the increased appearance of muscular attachments. Irregular melanization leads to lentigines, melasma, and poikiloderma, and prominent telangiectasias lead to erythema. It is in this area that many new developments have occurred.

Fillers, deep chemical peeling, and laser resurfacing can replace or encourage regeneration of lost dermal collagen. Botulinum toxin can be used to minimize the appearance of hyperkinetic muscles. Medium depth chemical peeling, cryosurgery, and intense pulsed light can be used to even out pigmentation abnormalities. Light sources, electrocautery, and sclerotherapy can be used for telangiectasias. This is an area of treatment where dermatology has much to offer.

Nonviable Epidermis

Dermatology also excels at treating the nonviable epidermis. It is in this area where desquamatory failure leads to retained corneocytes and poor skin texture. Superficial glycolic and salicylic acid chemical peels and microdermabrasion can enhance desquamation. Actinic keratoses can also contribute to poor skin texture, but are readily treated with 5-fluorouracil, diclofenac (Voltaren®, Novartis), imiquimod (Aldara®, 3M), or cryosurgery.

Stratum Corneum

The last area to consider is the stratum corneum. This is really the area of the cosmeceutical. It is the stratum corneum that is impacted by most of the creams for aging skin sold at the cosmetic counter. The most common treatable stratum corneum problem that leads to fine wrinkling is dehydration. In addition, the skin barrier may be in need of repair. A well-constructed moisturizer, e.g., Cetaphil® (Galderma) or CeraVe® (Coria Laboratories), creates an environment for healing in which the corneocytes and intercellular lipids can be restored to their normal brick-and-mortar lamellar organization. The stratum corneum also provides an opportunity to prevent photodamage through the application of sunscreens.

Conclusion

Dermatologists should consider a multiprong approach to photoaging by considering its effect on all of the facial structures, including the bone, fat, dermis, epidermis, nonviable epidermis, and stratum corneum. The best long-lasting solutions for the prevention and treatment of photoaging can be achieved through this multisystem approach.

References

1. Rossouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA 288(3):321-33 (2002 Jul).
2. Kratz A, Ferraro M, Sluss PM, Lewandrowski KB. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Laboratory reference values. N Engl J Med 351(15):1548-63 (2004 Oct 7).
3. Johannsson G, Bengtsson BA. Growth hormone and the metabolic syndrome. J Endocrinol Invest 22(5 Suppl):41-6 (1999).
4. Carr MC. The emergence of the metabolic syndrome with menopause. J Clin Endocrinol Metab 88(6):2404-11 (2003 Jun).
5. van Seumeren I. Weight gain and hormone replacement therapy: are women’s fears justified? Maturitas 34 Suppl 1:S3-8 (2000 Jan).

ABSTRACT
Over the past century, tanned skin shifted from being unpopular to becoming the height of fashion. However, the past decade has again seen white skin become fashionable as more and more people become aware of the dangers of spending too much time in the sun. Even so, having tanned skin is still popular and probably will be for some time to come. This article will focus on cosmetic products that are designed to simulate tanning of the skin by coloring or staining the skin without sun exposure. 

Key Words:
self-tanning creams, sunscreens

Despite extensive evidence that sun exposure induces premature cutaneous aging and skin cancer, patients continue to find tanned skin cosmetically desirable. Tanning booths are frequented by people of all ages from adolescent to mature patients and the industry is presently thriving in all regions of the United States. However, brown skin was not always fashionable. Wealthy females of the mid-to-late 1800s shunned sun exposure to the point of carrying parasols and spending extensive time indoors to distinguish themselves from farm labor who displaued deeply tanned skin from hours of working outdoors. As machinery replaced farm workers and indoor work behind a desk or in a factory became the norm, white skin became a sign that an individual did not have the luxury of spending time in the sun or vacationing in a sunny location. Therefore, as the work activities shifted indoors, a tan became fashionable.

Perhaps some of the education provided by dermatologists regarding sun avoidance is reaching fashion circles, as a review of the chic look for fall 1990 was white skin. Currently, the trendy makeup fashion is a powdered, matte, white face with vivid red lips and dark hair, but it is hard to imagine that “the tan” will loose its fashion desirability quickly.

Cosmetic products that imitate a summer tan fall into several categories: self-tanning creams, bronzing gels, bronzing powders and tinted moisturizers.

Self-Tanning Creams

Self-tanning creams, sold at both mass merchandisers and cosmetic counters, have become extremely popular because they produce a golden skin color overnight without sun exposure. These products are not new, but have seen a resurgence of popularity. This is because the new formulations produce a more natural golden color while the older products dyed the skin a somewhat unusual orange color. The golden color is quite acceptable on persons with blonde or light brown or light brown hair who tend to have golden hues to their skin, but it is not attractive on Mediterranean individuals with an olive complexion, or extremely fair persons with pink skin tones.

The active ingredient is 3-5% dihydroxyacetone incorporated into a glycerin and mineral oil base to form a white cream that turns the stratum corneum golden. A chemical reaction actually occurs between the keratin protein of the skin and the sugar component of the self-tanning cream. The resulting byproduct is a brown color that stains the skin. Formulations are available for the face and body, but most do not incorporate a sunscreen, nor is the golden skin color protective against actinic damage. Allergic contact dermatitis from use of the product is infrequent, but may be due to the incorporated fragrance or preservative.

The color is not permanent and is lost as the stratum corneum desquamates. Thus continues use is necessary. The major disadvantage of the product is that it stains all contacted skin surfaces including the palms of the hands, if it is not removed, and will produce deeper staining of the follicular ostia, seborrheic keratosis, actinic keratosis, porokeratosis and icthotic skin. Many patients are not aware that they have these skin conditions until the self-tanning cream highlights the irregularity.

Self-tanning creams cost from $15-$40 (US) for a 4-6oz tube and provide approximately 10-12 complete leg applications. Products are marketed to both men and women.

Dermatologists should ask patients about the use of a self-tanning cream before making the diagnosis of carotenemia from the appearance of yellow palms, or expressing undue concern of a lesion that has changed color. This may simply represent a stained stucco keratosis. Other than this confusion, self-tanning creams are safe and an excellent alternative to a tan from hours spent in the sun.

Bronzing Gel

Bronzing gels are pigmented polymers that are spread over the skin to simulate the appearance of a tan. They provide transparent color. Some products actually stain the skin, while others are removed with one washing, and still others incorporate a sunscreening agent in the formulation. Products are marketed through both male and female cosmetic lines and have become surprisingly popular with men.

Bronzing Powders

Bronzing powders are identical in formulation to face powders except for the addition of different pigments. The powder is stroked from a compact with a powder sponge or puff and applied to the body. The product is usually dusted down the central face, neck and shoulders to simulate a tan. The powder is easily removed by rubbing and provides slight physical sun protection due to the titanium dioxide in most formulations.

Tinted Moisturizers

Some moisturizers contain pigment that provides a sheer tanned appearance in addition to possessing emollient qualities.

Technically, it is impossible to separate a tinted moisturizer from a sheer, moisturizing facial foundation. Usually a facial foundation contains titanium dioxide to provide coverage to underlying cutaneous pigment defects whereas a tinted moisturizer does not, but the distinction is slight. Tinted moisturizers may or may not possess a chemical sunscreen.

Conclusion

Dermatologists may wish to familiarize themselves with cosmetics designed to simulate a tan for those patients who insist on displaying bronze skin. The cosmetics may or may not contain a sunscreening agent, but the color produced is not protective. Certainly, a cosmetic tan is safe alternative for patients who use a tanning booth or worship the sun.

References

1. Draelos ZK, Cosmetic in Dermatology. Edinburgh, Churchill Livingstone, 1990. Pp 25-30.