Clinics in Dermatology (2013) 31, 750–758

Anti-aging cosmetics: Facts and controversies

Marcia Ramos-e-Silva, MD, PhD ⁎, Livia Ribeiro Celem, MD, Stella Ramos-e-Silva, MD,
Ana Paula Fucci-da-Costa, MD
Sector of Dermatology and Post-Graduation Course, University Hospital and School of Medicine,
Federal University of Rio de Janeiro, Rio de Janeiro, 22280-020 Rio de Janeiro, Brazil

Abstract The authors review ageing in its extrinsic and intrinsic mechanisms, as well as the therapies
available for improving its effects, and present some of the facts and controversies related to anti-
aging cosmetics.
© 2013 Elsevier Inc. All rights reserved.

Introduction come no matter what, and this population obviously cannot

remain young forever, but a youthful appearance and good
In modern society, there is a great increase in the search health are essential.4,5
for eternal youth and an insatiable appetite for methods These days, many cosmetic innovations come about
which could turn back the clock. This has triggered an through scientific investigations. A wide range of skin-care
explosion in the cosmeceutical industry. The term products and their uses have become so extensive and
“cosmeceutical” was coined by Albert Kligman at the complex that physicians and consumers alike are often
national scientific meeting of the Society of Cosmetic confused about their indications and effectiveness. In the
Chemists in 1984, referring to topically applied products cosmetic field, many materials are commercially used and
capable of making changes to the skin status that are not claim to provide certain skin effects when used topically. In
considered drugs nor cosmetics that are applied to the general, although the effects may be small, they are
skin.1,2 The term remains controversial, especially among significant and can improve skin feeling and appearance
European authors.2 In the United States and Europe, with their continued use. It is difficult to compare and
cosmeceuticals are commercialized as cosmetics, although quantify the degree of the effects among the various
in Japan “a novel category of quasi-drugs exists that materials, because there are so many variables: measurement
encompasses these biologically active formulations sold of different specific end points; variation in equipment;
directly to consumers.”3 sensitivity of methods and formulation types, which can
In addition, technological advances in medicine for the affect material delivery into skin; and studies with different
prevention and treatment of deadly diseases help to increase body sites.
life expectancy. The elderly population has increased
significantly in recent years, both in developing and
developed countries.4 As an example, the baby boomers, Facial remodeling with the skin aging process
the 40 million Americans born between 1946 and 1963, are
approaching that stage of life where youthful good looks are Ageing produces a number of changes to the face, starting
becoming more of a memory than a reality. Skin aging will from childhood, which transforms the rounded contours of a
child's angelic face into a more angular face with defined
⁎ Corresponding author. Tel.: + 55 21 22864632. features, which will characterize the individual from the
E-mail address: [email protected] (M. Ramos-e-Silva). teenage years through adult life. These changes occur in the

0738-081X/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.clindermatol.2013.05.013
Anti-aging cosmetics 751

structures responsible for the formation of the facial Factors related to intrinsic aging
anatomy: skin, soft tissues, and bones.5,6 Ethnicity. The main effect of ethnicity on aging relates to
In childhood, the face, due to the great skin elasticity and the difference in pigmentation. High levels of melanin
distribution pattern of fat, presents a round format. The nose pigmentation protect from the cumulative effects of
and ear cartilage provide subtle and delicate contours, while photoaging. Black skin is more compact and has a greater
the bones are still in development. amount of lipids, also considered a factor that influences the
In adolescence, bones and cartilage reach the expected increased resistance to aging. 13 Asian subjects were
growth and then define facial contours. observed to develop wrinkles later and to a lesser degree of
From the third decade onwards, eyebrows start dropping, intensity as compared to Caucasians.14
causing the eyes to appear smaller. With the progression of Anatomic variations. Some areas of the skin are thinner
aging, in the fourth decade, the eyelids become more flaccid, than others and, in those thinner skin regions, aging becomes
leading to a pseudo-herniation of the retro-orbital fat and the more evident. This is especially noted on the eyelids, the
formation of rhytidosis. The nasolabial groove is more thinnest area of skin in the human body. There is also
prominent, and the eyebrows continue to drop. variability in both the composition and the distribution of
In the fifth decade, deep wrinkles appear in the forehead, lipids in the skin.15
and sagging eyelids result from the excess of skin. The jaws' Hormonal changes. Estrogens influence the synthesis of
arch loses regularity, and vertical wrinkles form around the collagen by fibroblasts, lead to the increased synthesis of
perioral region. hyaluronic acid, promote water retention, and increase the
In the sixth decade, wrinkles become more pronounced extracellular matrix. Conditions of hypoestrogenism, such as
and evident, even at rest. The dropping of the nasal tip and occur in the menopause, can have a deep effect on the skin,
mid-face structures is observed, which leads to the growth of because it becomes thinner and less hydrated. The
the nasogenian groove and loss of the jaw contour. The replacement of estrogens provides benefits in the skin
presence of excess of chin fat and platysmas sagging also rejuvenation of women during menopause.16
contributes to the modification of the jaw. Extrinsic aging. Extrinsic aging is due to controllable
In the seventh decade, the skin becomes thinner, factors and occurs at different degrees of intensity, due to
the eyelid opening gets further reduced, and facial fat solar exposure, smoking, and gravity, as well as other general
resorption occurs. lifestyle factors, such as diet, sleep, and overall health.10
In the eighth decade, all prior changes are much
more evident. Thinning of skin and fat resorption Extrinsic aging related factors
continue progressing.7 Ambient conditions. High temperatures lead to increased
water evaporation, while low temperatures provide a
hardening and reduced water loss through the same
mechanism, even with abundant air moisture. The appropri-
Intrinsic and extrinsic aging ate formation of structural proteins and lipids in the skin
depends on the environmental temperature.17
The two types of skin aging have distinct sources: the Drugs. Hypocholesterolemic agents can induce xeroderma
intrinsic and extrinsic; however, their results become and desquamation.18
synergistic, leading to the aged look of the skin.8,9 Smoking. Smoking has been identified as an important
contribution to facial wrinkles, even more than solar
Intrinsic aging exposure. There is a parallel between the smoking load and
the emergence and intensity of wrinkles.19 Smoking induces
Intrinsic aging, also called true or chronological aging, several harmful modifications: elastosis, telangiectasias, and
inevitably occurs as a natural consequence of physiological decrease of blood flow in the capillary vessels, leading to the
changes over time. In this case, individual genetics are deprivation of nutrients in cutaneous tissues.20 Additionally,
responsible for the interference, among other factors that are there is a reduction of collagen fibers and elastin in the
also present but with less effect.10 Currently, telomeres, dermis and in the lung, plus an increase of free radicals.
small DNA sequences present at the ends of chromosomes, There is also an increase of keratinocytic dysplasia and
are considered as essential elements in the intrinsic aging skin roughness. 21 Hormone replacement therapy does
process. These structures, when intact, tend to extend the life not bring cutaneous benefits to patients who have been
of cells. With aging, due to a continuous replication, a long-time smokers.22
shortening of these structures occurs, which can be repaired Sunlight exposure. Photo-exposure induces an avalanche
by telomerase. The maintenance of telomeres by the action of of molecular and cellular changes that trigger a fast and
telomerase would lock the aging process, but this action can dynamic disorder in the skin, unlike intrinsic changes, which
lead to carcinogenesis.11 There are still no systemic or occur slowly, producing a generalized atrophy and few
topical treatments based on this theory, and more studies structural changes until age 50. The effects of sunlight on the
are necessary.12 skin are deep and represent up to 90% of the visible aging of
752 M. Ramos-e-Silva et al.

the face's skin, mainly in patients with light skin.17 The 2. The second strategy uses formulations with active
changes induced by exposure to sunlight will be cited and substances to try to postpone or even reduce the signs
compared in the table below. and symptoms of aging. Retinoic acid, alphahydroxy
These two forms of aging are responsible for different acids, antioxidants, estrogens, and growth factors have
skin changes accountable for generating the senile face in a been deployed in this sense.
synergistic manner (Table 1).23–34 3. The third strategy is employed when a more serious
form of aging presentation is already manifested,
requiring more invasive mechanisms, such as chemical
peeling with a higher acid concentration, use of lasers,
Current treatments for aging skin injection of fillers and botulinum toxin, and so forth.
4. The next sections will focus on what we have now for
Rabe et al.35 proposed the creation of 3 groups of cosmetic treatment, including retinoids, alpha hydroxy
strategies for planning the treatment and prevention of aging acids, antioxidants
skin (Table 2). They are listed below:

1. The first approach aims at preventing photoaging through

the use of sunscreens with chemical or physical broad- Retinoids
spectrum filters. Gaining a more conscious behavior in
relation to photo-exposure must also be stimulated in In the epidermis, retinoids normalize the life cycle of
patients, in an attempt to prevent solar damage. keratinocytes, reduce keratinocytic atypia, and normalize the

Table 1 Comparing photoaging to intrinsic aging23

Characteristics Photoaging Intrinsic aging References
Overall
Metabolic processes Pronouncedly increased Slowed down Soter24
Clinical appearance Nodular, leathery, blotchy Smooth, unblemished Glogau25
Coarse wrinkles, furrows Loss of elasticity, fine wrinkles
Skin color Irregular pigmentation Pigment diminishes to pallor Rees26
Skin surface marking Markedly altered, often effaced Maintains youthful geometric patterns Gilchrest27
Onset As early as late teens Typically 50s-60s (women earlier than men) Kligman28
Severity Strongly associated to degree of pigmentation Only slightly associated to degree of Rees29
pigmentation
Epidermis
Thickness Acanthropic in early stages, Thins with aging Takema30
atrophy in later stages
Proliferation rate Higher than normal Lower than normal Lavker31
Keratinocytes Atopic and polarity loss, numerous dyskeratoses Modest cellular irregularity Kligman32
Dermo-epidermal Extensive reduplication of lamina dense Modest reduplication of lamina densa Gilchrest27
junction
Vitamin A content Destroyed by the sun exposure Plasma content of retinol increases Seité33
Dermis
Elastin Marked elastogenesis followed by massive Elastogenesis followed by elastolysis – Kligman32
degeneration, dense accumulation on fibers 'moth-eaten fibers'
Elastin matrix Massive increase in elastic fibers, replacing Gradual decline in production of dermal Hanson34
the collagenated dermal matrix matrix, only modest increase in the number
and thickness
of elastic fibers in the reticular dermis
Lysosyme deposition Increased Modest Gilchrest27
on elastic fibers
Collagen production Decrease in amounts of mature collagen Mature collagen more stable in degradation Lavker31
Grenz zone Prominent Absent Lavker31
Microvasculature Abnormal deposition of basement membrane- Normal Gilchrest27
like material
Microcirculation Vessels become dilated, deranged Microvessels decrease; remaining vessels Gilchrest27
do not change
Inflammatory response Pronounced inflammation, perivenular No inflammatory response observed Gilchrest27
histiocytic-lymphocytic infiltrate
Anti-aging cosmetics 753

Table 2 Photoaging therapies categorized by type of environment with minimal exposure to oxygen and light. The
treatment/prevention strategy and disease severity35 primary package of the final product should also be
Primary Secondary Tertiary impermeable to oxygen and opaque. Other strategies can
also be used, such as retinoid encapsulation and inclusion of
Photoprotection Photoprotection Chemical peelings
stabilizing antioxidants.41
Retinoic acid Microdermabrasion/
The use of retinoid in relation to its safety for women of
microcoblation
Antioxidants Laser child-bearing age is still controversial. During the past 20
Estrogens Botulinum toxin years, no long-term side effects have been observed in young
Growth factors/ Fillers adults using tretinoin, but there may be a problem for women
cytokines who want to become pregnant. Oral retinoid is a known
teratogenic drug, and this creates a dilemma for prescribing
topical tretinoin. There is a need for studies that could
spread of melanosomes. Dermal changes are represented by establish beyond doubt whether it is absorbed and at what
an increase of collagen, elastin, and glycosaminoglycans. percentage. Some studies have demonstrated that less than
Histopathologically, these changes are expressed by struc- 2% of topical tretinoin is absorbed, and the quantity that can
tural changes in solar elastosis and collagen degeneration, be detected in blood after many applications is much less
Langerhans cell restoration, and correction of dysplastic than blood levels of vitamin A. Researchers reported a case
changes.28,36,37 of ear malformation in a baby born to a woman using
Retinoic acid (tretinoin) is considered one of the most tretinoin cream.42 In a study of 215 women exposed to
powerful compounds to treat the signs of aging, including topical tretinoin early in pregnancy, topical tretinoin was not
fine lines and stains, but it should be used cautiously to associated with an increased risk for major congenital
avoid producing undesirable effects, such as stinging defects.43 At present, it is best to advise young women not
and burning. Newer delivery systems may diminish the to use topical retinoids during pregnancy or when they are
unwanted effects.38 trying to become pregnant.44
Retinol (vitamin A), the biologically active form of Another question to be considered is the use of retinoids
vitamin A, presents topically only a small retinoid-like action in sun protection. Topical retinoids have been used in
when compared to the topical retinaldehyde and retinoic acid sunscreens as antioxidants, but this use is controversial.
in in vivo studies.39 It also has antioxidant action. Retinoids do not offer any ultraviolet blocking or protection,
Retinaldehyde, an intermediate formed during the con- although they may offer some beneficial effect on free
version of retinol into retinoic acid, also shows benefits in radical scavenging. Retinylpalmitate is an ester of retinol and
reducing wrinkles.40 is also believed to have antioxidant properties. It is included
Much of the published literature on the use of retinoids to in some sunscreens to reduce the risk of skin cancer. It is
improve skin wrinkle appearance is focused on topical also used as a vitamin supplement and sometimes added
retinoic acid, but there is also information on the cosmetic to low-fat milk. It is neither an active sunscreen nor a
vitamin A compounds, such as retinol and retinyl propio- sunscreen preservative.45
nate.14 In general, retinoids are very potent, so topical doses Because topical retinoids may cause a reaction with
of less than 1% are typically sufficient to obtain significant erythema, desquamation, pruritus, and a burning sensation
effects. At low doses, in double-blind, split-face, placebo- (“retinoid reaction”) in a high percentage of patients, some
controlled facial testing lasting 12 weeks, retinol and retinyl people may think that retinoic acid improves photoaging,
propionate were both significantly effective in reducing the because it irritates the skin. Some patients end up not
appearance of facial wrinkles and hyperpigmentation. adhering to the treatment, although many patients show
Clinical studies have also been published on other retinoids. improvement without any retinoid reaction. For this
Retinaldehyde, typically at a dose of 0.05%,15–17 is clinically reason, each treatment must be individualized, and the
effective. Retinylpalmitate has low irritation potential but dermatologist needs to explain very carefully what the
also weaker efficacy, even with a very high concentration of patient can obtain, as well as the possibility of side effects.
2% required to observe an effect.18 The dermatologist must be sure that there are no contrain-
The choice of retinoid may reduce skin irritation. Retinol dications, such as the existence of photosensitivity and
is better tolerated by skin than trans-retinoic acid, 5 pregnancy. Tolerance will depend on skin type, race, age,
retinaldehyde has an irritation potential similar to retinol,19 and the extent of photodamage.
and retinol esters are better tolerated than retinol.14 Irritation
may also be mitigated to some extent by formulation to
control skin delivery or inclusion of other ingredients such as Alpha hydroxy acids (AHA)
anti-inflammatory agents. The second main concern is
instability, especially in the presence of oxygen and light. AHA were introduced by Eugene Van Scott in 1984.46
To increase retinoid stability in the finished product, There are several types of AHA, with the most used being
formulation and packaging should ideally be done in an glycolic, citric, lactic, malic, pyruvic, and tartaric acids. They
754 M. Ramos-e-Silva et al.

present an action mechanism that is not well-clarified, but wrinkles, and lentigines, but it is unable to protect against
one hypothesis suggests that AHA would reduce the induced erythema or UV damage.52
concentration of calcium ions in the epidermis and, through
chelation, would remove the ions from the cells' adherence, L-Ascorbic acid (vitamin C)
resulting in desquamation. The reduction of calcium ion Vitamin C is routinely used in topical formulations, due
levels tends to promote growth and cell differentiation, thus to its stimulating effect on the synthesis of collagen and
generating younger-looking skin. Its action, on the other antioxidant property. It inhibits tyrosinase, reducing areas
hand, is known to be beneficial to the photo-aged skin by with hyperpigmentation, and provides some protection
reducing the corneal layer, normalizing the cohesion of the against UV radiation by its antioxidant properties.53 Some
stratum corneum, and inducing epidermal and dermal authors report that there is no consistent clinical data
thickening by the accrual of dermal glycosaminoglycans, supporting the use of topical C vitamin for improving fine
besides improving lines and wrinkles and increasing lines and reducing pigmentation and inflammation. 54
collagen density.36,47,48 Others who share the same view state that these
AHAs in high concentrations are used as chemical peels formulations are not effective on the skin due to a very
for exfoliating the stratum corneum, allowing its renewal and low concentration of L-ascorbic acid or because the product
thus leaving the skin smooth and with fewer stains.48,49 The is affected by exposure to air and light, compromising its
use in these higher concentration is controversial, because stability. Additional studies report that the L-ascorbic acid
skin erythema and flaking are listed as major side effects, molecule (in the form of an ester or a mixture of isomers)
which become more pronounced as the concentrations of the could not be effectively absorbed or metabolized through
products increase. AHAs are also known to increase skin the skin.49.54
photosensitivity, and it has been shown that glycolic acid and One concern about the addition of ascorbic acid to
ultraviolet-B (UVB) radiation inhibit proliferation and cosmeceuticals is that it is innately unstable in formulation;
induce apoptosis in human keratinocytes.50 it is unclear how much, if any, intact molecule remains on
the skin. This problem has been partially overcome by
Antioxidants chemically modifying ascorbic acid through esterification
of the hydroxyl group, but for the skin to use the supplied
Antioxidants are responsible for reducing the damage ascorbic acid, it must convert it to L-ascorbic acid. Many
caused by free radicals, thus avoiding damage at the of the stabilized commercially available forms have not
cellular level. They also help to inhibit inflammation and been examined to determine whether this conversion is
offer protection against photo-damage and skin cancer. possible or if they penetrate cutaneous tissues to the same
Antioxidants include alpha-lipoic acid (ALA), L-ascorbic extent as L-ascorbic acid. One study revealed that optimal
acid (vitamin C), niacinamide (B3 vitamin), α-tocopherol, delivery of stable L-ascorbic acid into the skin occurred at
and ubiquinone. a pH of less than 3.5 and at a concentration less than 20%.
Because the topical application of sunscreens does not This same study showed that magnesium ascorbyl
offer complete protection against UV damage, antioxidants phosphate, ascorbyl-6-palmitate, and dehydro ascorbic
play a major role in the prevention and therapy of UV- acid (other ascorbic acid derivatives) on a daily application
induced skin aging and are being added to the formulations did not increase levels of L-ascorbic acid in the skin,
for sun protection.51 calling into question their ability to improve the aged skin.
A new concept, such nutricosmetics are also known as Not all formulations containing ascorbic acid should be
“beauty pills,” “beauty from within,” and even “oral considered equal; it is essential to determine which specific
cosmetics.” This product category is formed by the modified form is included and to examine whether that
intersection of cosmeceuticals and nutraceuticals. The term particular form has been tested for clinical efficacy.
nutraceutical was defined by DeFelice as “any substance that Presently, it seems prudent to recommend the use of L-
is a food or part of a food that provides medical or health ascorbic acid for the treatment of photoaging, because
benefits, including the prevention and treatment of disease. there are promising clinical results and no major side
The major claim is the antiaging effect, reducing wrinkles by effects, but there is not sufficient evidence in the form of
fighting free radicals generated by solar radiation. Among clinically controlled trials to support the use of the more
the ingredients used in nutricosmetics, antioxidants are the stable derivatives of ascorbic acid, which are most
most crucial.1 The concept of nutricosmetics is new and has commonly found in today’s cosmeceuticals.55
recently been a frequent subject of scientific research;
however, they deserve greater attention in relation to clinical Vitamin E
studies and regulation. Vitamin E has an antioxidant and moisturizing property.
Some studies have demonstrated that it has topical action in
Alpha-lipoic acid (ALA) the protection against UVB radiation damage.56. Other
Alpha-lipoic acid has anti-inflammatory properties and actions are the acute reduction of erythema in sunburns,
acts as an exfoliant, possibly helping in reducing roughness, tanning, and photoaging. Its association with vitamin C
Anti-aging cosmetics 755

demonstrates synergistic effects, in particular, because it is Moisturizers

capable of regenerating oxidized vitamin E.57
Unlike oral vitamin E, the application of topical vitamin E Moisturizing agents are responsible for keeping water
has been recognized as a safe substance with adverse in the epidermis; besides promoting a protective film
reactions generally limited to a slight irritation.58; however, against water loss, they help maintain the barrier. They
there are no data to support any effect of vitamin E in topical should be used in support of the use of home formulations for
therapies purporting improvements in skin wrinkling, skin rejuvenation.49
discoloration, or texture, although there is a plethora of
products available on the market that contain various forms
of vitamin E. Scientific data also has not shown which, if
any, commercial form of the vitamin might have the best Peptides
penetration and bioavailability. What this means clinically
with respect to photoaging remains a question requiring Peptides are part of a group of agents that seem to act as
further investigation.55 cellular messengers. They are formed from amino acids that
mimic fragments of endogenous peptides with biological
Ubiquinone or idebenone (CoQ10) activity.64
Derived from co-enzyme Q10, idebenone is a powerful There are three categories of peptides: carrier peptides
antioxidant able to stimulate collagen production, to inhibit (matrixyl), neuro-transmitters (argyreline), and enzyme
the oxidative stress generated by UVA and UVB,59 and to modulators (rice and soy proteins).3 Opinions are still
protect the dermal matrix, both in intrinsic and extrinsic conflicting, and some people state that there is no significant
aging.60 So far, only one study showed wrinkle improve- evidence that they work better than moisturizers, although
ment, using 1% CoQ10 cream for 5 months.51 investigators claim that it could be a group of substances with
future potential.65
Niacinamide (vitamin B3) Peptides are already found in a large number of cosmetic
Niacinamide is a powerful and well-tolerated antioxidant. products,3 but because there are plausible severe conse-
It promotes improvement in the lipid compound of the quences of introducing materials into cells and modulating
epidermal barrier, reducing transepidermal water loss. It also transcription factors and because there is very little
acts as a melanosome transfer inhibitor, improving hyper- information in the literature concerning adverse events
pigmentation. Studies have shown a significant reduction of after the use of topical peptides, peptides should be used
fine lines, wrinkles, and hyperpigmentation, as well as with extreme caution.66
improvement in skin elasticity.61,62
Several reports have documented the range of cosmetic
effects of topical niacinamide. These data emerged from
several double-blind, placebo-controlled, left-right random- Hormone replacement therapy
ized, split-face studies. Topical niacinamide has significantly
improved skin color, for example, including the reduction of Hypoestrogenism affects the skin, producing less hydra-
hyperpigmented spots and red blotchiness. The latter effect, tion and thinning the skin; therefore, its replacement, when
in particular, may be related to the skin barrier improvement, well prescribed, including hormones in topical formulations,
reducing skin sensitivity and responsiveness to environmen- is effective in rehydration, collagen increase, and dermal
tal insult, such as from surfactant exposure. Fairly high doses thickness.16
(2% to 5%) of vitamin B3 have been used to achieve these Long-term prospective, randomized, double-blind, place-
desired effects. Because the skin has a very high tolerance to bo-controlled studies on hormone replacement therapy in
niacinamide even with long-term usage, high doses can be women have shown that skin aging signs were reversed
used acceptably. Some clinical data on myristoyl-nicotinate and skin elasticity, hydration, and thickness were signifi-
have also been presented34 to suggest that a similar broad cantly increased.67
array of effects occurs with this agent when used topically at Enhancing collagen production with topical estradiol
doses of 1% to 5%. seems to be restricted to intrinsically aged skin51; however,
The most important challenge of working with niacin- long-term studies to evaluate the safety of systemic HRT
amide and nicotinate esters is avoiding hydrolysis to for skin anti-aging purposes are necessary because
nicotinic acid. Nicotinic acid, even at low doses, can induce contraindication to HRT includes a history of breast cancer
an intense skin reddening (flushing response).63 Formulating or endometrial cancer, recent undiagnosed genital bleeding,
in the pH range of 4 to 7 is preferred to avoid hydrolysis. For active severe liver disease, and a history of thromboem-
this reason, formulations containing both niacinamide and bolism. On the other hand, topical therapy with estradiol
acids, such as salicylic acid, or bases, such as zinc oxide, are preparations was reported to have significant anti-aging
problematic. Many commercial options are available for the effects and may therefore provide an alternative to
nicotinate esters. systemic therapy.68
756 M. Ramos-e-Silva et al.

Sun blockers cosmetics therapies available and the controversies related to

their efficacy.
Sun blockers are essential for skin health and rejuvena- Before trusting the promises of each cosmetic product,
tion, given that they provide protection against the most one should analyze the hormonal and genetic factors, as well
important factor for skin aging: exposure to sunlight. as anatomical variants, considering that they, alone, generate
They must be of broad spectrum, that is, they must protect limits to the success of the cosmetic product to each type of
from both UVA and UVB. The photo-protection is physical skin. The dermatologist must remember that many of these
when the sun blockers contain reflective agents such as zinc products are still controversial.
oxide or titanium dioxide. These substances are inert and Factors related to intrinsic aging have their value, when
present a lower possibility of causing allergic reactions. we think about choosing the best cosmetic for each type of
Chemical blockers absorb and react to sunlight to make it skin. The selected site for treatment greatly influences the
nondamaging. Some blockers are an association of both. result, because there some areas of skin are thinner and others
Their use on the face and other photo-exposed areas must thicker. Patients with more melanin due to ethnicity will
become a daily habit.69 present with different results from the same product.
Controversies as to the daily use of sun blockers Similarly, we should consider sun exposure and smoking,
remain. Concerns have been raised about the safety of among other extrinsic factors, because they can modify the
micronized titanium dioxide, topical oxybenzone, and the skin and reduce the effectiveness of treatments that give
sunscreen additive retinylpalmitate. The FDA and con- good results in people who systematically avoid exposure to
sumer groups are conducting studies about the localized the environment.
effects, such as carcinogenesis, and potential side effects of To avoid all existing controversies related to the
systemic absorption.70 Many discussions are arising daily efficacy of specific cosmetic treatments, it is advised that
regarding use of sunscreens versus vitamin D and calcium we know exactly what we, as physicians, and our patients
metabolism. In theory, correct usage of sunscreens should are looking for with a specific treatment and with what
significantly reduce vitamin D levels, but this is not the type of skin we are dealing, so we can choose the ideal
case in practice. product or products.
Several studies have demonstrated that sunscreens are
rarely applied correctly, in the right dosages, and with
appropriate frequency. In real-world conditions, it is likely
that the improper use of sunscreen and/or increased exposure References
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