A questionnaire was sent to the experts in October 2022. For each case scenario, the panel of experts rated the benefit-to-harm ratio of 17 ingredients for topical dermocosmetics (Table 1) on a scale from 1 (totally inappropriate: therapeutic never used; the expected harms greatly outweigh the expected benefits), through 5 (uncertain), to 9 (totally appropriate: choice therapeutic; the expected benefits greatly outweigh the expected harms).
Dermocosmetic ingredients for which a consensus had not been reached in the first round were discussed in a virtual meeting and further statistical analysis was performed. After consensus was reached, a second meeting and email discussions reviewed/validated the decisions.
Hypothetical Case Scenarios
Eight hypothetical case scenarios were prepared (by ZD and SLM) as representative examples of the many diverse populations seen in daily dermatological consultations:
Scenario 1
A 30-year-old female with FST IV has a 3-month-old son and recently noticed upper lip, bilateral jawline, and lateral forehead pigmentation. The presence of the dyspigmentation is emotionally distressing and is contributing to her post-partum depression. She has been avoiding public situations for the past months due to her appearance. She has tried several over-the-counter products without results. She is concerned that the melasma pigmentation continues to darken despite her avoidance of the outdoors and wonders why this is happening. She does not wear photoprotection as she is dissatisfied with the sunscreen appearance on her skin.
Scenario 2
A 25-year-old female with FST III is noticing the first signs of aging with fine lines around the eyes. She also has post-inflammatory hyperpigmentation (PIH) from acne scarring that is both recent and old. She uses only bar soap on her face and frequently goes to sleep without removing her cosmetics. She desires recommendations for a good acne prevention skin care regimen. She has been reading about the baby-botox trend and wonders if this is an option for wrinkle prevention; however, she is needle phobic and not sure she wants to put a toxin into her body.
Scenario 3
A 30-year-old FST II female with sensitive skin who works outdoors as a landscape architect desires to initiate anti-aging cosmetic solutions as she has lentigines on her face along with fine glabellar lines and facial dryness. She has a 6-month-old daughter and has noticed the difference between her skin texture and that of her daughter. She frequently gets fewer than 5 hours of sleep nightly, in between her work responsibilities and her daughter not sleeping through the night.
Scenario 4
A 35-year-old FST III male is recently divorced and wishes to renew his interest in dating. He has frequently consulted a dermatologist for treating his cystic acne. He completed a course of oral isotretinoin 3 months ago and is noticing a few isolated papules and pustules and xerosis. He wishes to resume sky diving but has not jumped for the past 6 months due to photosensitivity created by the oral retinoid. He also wants to both improve his appearance and prevent photoaging.
Scenario 5
A 40-year-old female with FST I has always used sunscreen and taken care of her health, but she works in a youth-oriented fashion environment and feels pressure to do more for her appearance. She has initiated botulinum toxin treatment for her glabellar lines and had hyaluronic acid injected into her nasolabial folds. She is satisfied with her anti-aging procedures but wants to improve her skincare regimen to address her suboptimal skin texture. She lives and works in New York City and is concerned about the effect of pollution on her skin.
Scenario 6
A 45-year-old perimenopausal female with FST II and pigmentation wishes to improve her skin performance. She has tried various dermocosmetics without the rapid results she desires; therefore, she elected to have a carbon dioxide laser resurfacing procedure and wants recommendations for both pre- and post-procedure skin care. She exercises infrequently and is about 40 pounds/18 kilos overweight but has recently started dietary counseling. Her goal is to re-enter the workforce with a revitalized appearance.
Scenario 7
A 45-year-old menopausal female with FST IV has just started a successful career as a live on-location television reporter. With the increased outdoor activities and sun exposure, she is noticing actinic pigmentation on her bilateral cheeks. She desires counseling on sunscreen selection that will not appear white and pasty on her skin, yet will provide excellent sun protection. Additionally, she has started noticing that, accompanying the occurrence of hot flashes, her skin aspect is changing, and she no longer tolerates her usual cosmetic routine. She is wondering if there is a problem with her skin and seeks advice on why this could be happening.
Scenario 8
A 60-year-old menopausal female with FST I desires suggestions to improve her appearance. Until her recent retirement, she was a heavy smoker (half a pack of cigarettes daily) due to the stress of her job. She notes upper lip and jawline dyspigmentation that has worsened considerably since she began estrogen replacement therapy.
RESULTS
Results of the consensus reached by the 7 international experts between November 2022 and April 2023 on the appropriate dermocosmetics for each scenario are shown in Figures 1 and 2. Broad-spectrum high sun protection factor (SPF) and high ultraviolet (UVA) photoprotection with PF at the base of the pyramid was universally considered appropriate for all scenarios, all FST, and both sexes. Topics that were discussed in more detail to reach a consensus concerned the use of tinted sunscreen with iron oxide particles with dark skin, the use of antioxidants, exfoliating ingredients and retinols with sensitive skin, dermocosmetics for men, and other antioxidants.
In scenario 1 with melasma, tinted sunscreen/iron oxide are recommended for lighter Fitzpatrick skin types I-III, especially for women. Protection against visible light (VL; specifically high-energy visible or blue light) is especially important for darker skin types (III-VI) as they are more sensitive to pigmentary disorders from blue light, therefore, tinted sunscreens/iron oxide are recommended if cosmetically acceptable. However, compliance may be sub-optimal for darker phototypes (FST IV-VI) as the range of colors of tinted sunscreens are limited and may not match the patient's constitutive skin tone, leaving a greyish/whitish aspect. The experts, therefore, recommend combining a facial foundation that perfectly matches the patient's skin tone with tinted broad-spectrum sunscreen containing iron oxides (UVA, UVB, VL) or non-tinted mineral sunscreen, as a solution to obtain VL protection for darker phototypes that closely color matches diverse color tones, including dark phototypes.
In scenario 1, antioxidants are recommended for all FST.
In cases of sensitive skin (scenario 3), retinols (present in numerous antiaging products) can be irritating for all phototypes, especially FST V and VI (risk of paradoxical worsening), so they should not be recommended as a first-line treatment. However, suitability will depend on the retinol formulation, concentration, and effectiveness. Additionally, retinoids should be avoided if breastfeeding.
AHA including glycolic acid should also be avoided as they enhance photodamage by UV light.
