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medical beauty research

we provide general information about anti-aging research. Anti-aging research focuses on understanding and slowing down the aging process, particularly as it relates to the deterioration of the body's cells, tissues, and organs. This research involves exploring the biological, genetic, and environmental factors that contribute to aging, as well as developing interventions and treatments that can help delay or reverse age-related changes. Some examples of anti-aging interventions include lifestyle modifications, such as healthy eating and exercise, as well as the use of skincare products and other anti-aging treatments.

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Nam Vo Says This $1,750 "Liquid Surgery" Serum Is Worth the Hype

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You only have to go onto Nam Vo's Instagram for half a second to start envying what the New York City-based makeup artist calls her "dewy dumpling" glow . Luckily, she often shares the secrets to her luminous skin on her Instagram stories. Recently, she posted a picture of the MBR Liquid Surgery Serum she's been slathering on lately, noting it's the most expensive product she owns (it's $1,750). She even joked that she was "accused of being a 12-year-old yesterday and a 16-year-old today."

The pricey serum with a wild name was gifted to Vo by one of her favorite New York City-based aestheticians, Aida Bicaj. So I asked her how she discovered the product. Turns out, MBR found her first. In 2015, she met the company's CEO and was introduced to the serum. The same year, MBR launched in the US, and Bicaj loved the products so much that her namesake spa was the first place in America to sell it.

The Liquid Surgery Serum appealed to her as it's spiked with a proprietary complex that contains synthetic perfluorocarbons, which help carry oxygen to skin. As the serum absorbs, oxygen is said to replace the excess carbon dioxide in dermal tissue to purportedly help "produce a youthful, radiant, ageless complexion" Bicaj says.

"Generally, the oxygen content and the skin's ability to deliver oxygen to the dermal tissue decreases gradually starting at the age of 20, and by the age of 50, it reaches only half of the original value," she further explains. "The percentage of carbon dioxide increases proportionally. A lack of oxygen at the cellular level causes aging, increasing lines to wrinkles and the forming of age spots."

As much as I wanted to take Bicaj's word for it, I was still skeptical about how a serum could possibly give your skin plastic surgery-like results without added pain or downtime. I took a closer look at its ingredients and how much it takes to actually make the product.

As someone who finds joy in reading the ingredient list of skin-care products the way some people do about their favorite basketball player's stats, I looked forward to checking out what makes up the Liquid Surgery Serum. The list was surprisingly short but just as mind-boggling as its price. Many of them had trademark symbols and registered signs next to them and fancy proper names, like Pentavitin, CroNoline, and Syn-Ake. The only ones I recognized were ceramide, shea butter, and hyaluronic acid.

To learn more about how the serum is supposed to smooth skin and iron out wrinkles, I sent the ingredient list to a couple of cosmetic chemists, as well as a dermatologist. Many pointed out that I probably didn't recognize most of the ingredients because the trademarked ones are raw materials from outside manufacturers that MBR combined into its formula.

• Ceramide III: Like the ceramides that spike some of the latest and greatest skin-care products on the market, this form is "a human-skin identical fat molecule that is a vital part of our skin barrier," explains Arash Akhavan, a New York City-based cosmetic dermatologist. "It helps to repair dry and sensitive skin."
• Shambrilla oil: Derived from a flowering plant native to California and Oregon, shambrilla oil is an emollient that "makes the product feel slippery and soft on skin," says cosmetic chemist Perry Romanowski.
• Shea butter : A better-known emollient that also has occlusive qualities.
• Hyaluronic acid
• Pentavitin: Cosmetic chemist Ginger King calls this simply a "moisture magnet."
• Liquid Surgery Complex (perfluorocarbons): "Perfluorocarbons are a class of man-made compounds made of fluorine and carbon that increase oxygen delivery to the skin," says Akhavan. King says they have healing potential. Akhavan adds: "No significant benefit has been proven scientifically, but it is said by some to increase collagen production and skin hydration."
• Golden Collagenine: This one is "a peptide containing precious metals like gold and platinum," Romanowski explains. "There's little evidence it does much when put on the surface of skin."
• Complex from Syn-Ake: This synthetic peptide works as a muscle relaxant. When applied topically, "this compound can help to relax facial wrinkles," Akhavan says.
• Trylagen: This combination of peptides and proteins is said to boost collagen production, according to Akhavan. There's little evidence to back that claim up, though, Romanowski adds.
• Cyclopeptide-5: This particular peptide has been shown to decrease sagging and wrinkles, says Akhavan.
• CroNoline: "This ingredient is a mystery to me," Akhavan admits. "I can't find anything on it."
• SYN-HYCAN: The last peptide on the list is moisturizing, notes Romanowski. It supposedly "boosts hyaluronic acid production in the skin and strengthens collagen fibers," Akhavan adds.

Now that the science lesson is over, let's talk finances. All the trademarked ingredients are what hike up the price of the serum, the experts conclude. Although none of them know just how much of each ingredient is used in the final formulation, in Romanowski's opinion, "there is no serum on Earth that would be worth $1,750." He suggests instead using a product like the $29 Olay Regenerist Regenerating Serum instead as he says you'll likely get similar wrinkle-reducing benefits from it.

Regardless of how much of each of the expensive ingredients are added to the serum, King is doubtful that your skin could absorb all the actives in it. "Cosmetics, by definition, should not penetrate deep into the skin — or it's a drug," she explains. "So, it's like spending $1,750 versus $100 for a pool cover. It may make you feel fancy but it's not necessarily doing you any better than a $150 product — that's my limit that I am willing to pay, as a cosmetic chemist, for a good [skincare] product."

Picking which skin-care products you used on your face every morning and night is completely a personal choice. Spend $10, $100, or $1,750 — as long as the product isn't irritating your skin and making it break out, feel free to do whatever you want. Skin-care polices don't exist.

This serum most likely won't replace the wrinkle-reducing results of Botox or the skin-tightening benefits of a face-lift . But if you're terrified of needles and getting surgery and happen to have the money to spend, this is an incredibly luxurious way to treat your skin.

You can shop the MBR Liquid Surgery Serum on mbrskincare.com . I would invest my money elsewhere, and buy something under $100 instead. But, that's just me.

Read more about beauty splurges that are worth it:

• I Hate Spending Money, But I’d Buy This $125 Best of Beauty Award-Winning Palette ASAP
• Why the Christian Louboutin Rouge Louboutin Velvet Matte Lipstick Speaks to My Scorpio Sensibilities
• The 21 Best Luxury Beauty Products That Are Worth the Splurge

Now, watch a fun glass skin tutorial:

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BIOCHANGE ®

BioChange ® is an essential skin care collection, combining state-of-the-art science with carefully selected and highly effective ingredients. BioChange ® products protect against persistent environmental stress and maintain ageless beauty. By reviving the natural cell functions, the skin’s ability for a deep regeneration process is activated with sustainable effect.

BIOCHANGE ® CEA

BioChange ® CEA restores the skin’s functional balance with a luxurious synergy of science and nature. State of-the-art technology is combined with carefully selected, highly effective ingredient complexes to boost and sustain the skin’s ability for deep regeneration, refined tone and texture while maintaining ageless, glowing and beautiful skin.

CONTINUELINE MED ®

ContinueLine med ® is a perfectly attuned skin care collection for sensitive, irritated, uncomfortable and very dry skin. Rare, exquisite ingredients effectively restore the skin’s physiological balance while soothing the natural protective functions of irritated, uncomfortable skin with the tendency for eczema and rosacea. Irritated skin is deeply calmed, resulting in a balanced, even skin tone with youthful luminosity.

BIOCHANGE ® CYTOLINE ®

BioChange ® Cytolyne ® is a definitive solution in the fight against aging that includes biologically active polypeptides for deep nourishment, and Cytokines that stimulate cellular movement and intense regeneration of the collagen and elastin fibers. The skin’s volume and elasticity is effectively restored and strengthened resulting in a visibly rejuvenated and radiant complexion.

BIOCHANGE ® ANTI-AGEING BODY CARE

BioChange ® Anti-Ageing Body Care is a age defying body treatment system. Enjoy instant indulgence and visible results with this advanced anti-aging collection for specific body concerns. The lavish, customized body cream care regimen includes vitamins and peptides to deeply nourish, lift and smooth – capturing ageless beauty and wellbeing from head to toe.

PURE PERFECTION 100 N ®

Pure Perfection 100 N ® is a skin perfection collection for ageless beauty. Experience flawless skin and ultimate rejuvenation with precious, revolutionary ingredients in their most potent concentration. Formulated to improve the appearance of all signs of aging, the skin is stimulated and deeply nourished revealing an exceptional and truly transformed, youthful looking complexion.

PURE PERFECTION 100 N ® THE BEST

Pure Perfection 100 N ® THE BEST is a luxurious, revolutionary collection that transforms the skin, by reactivating the cellular level. THE BEST utilizes the revolutionary MBR® FibroBoost Complex, a patented anti-aging peptide that profoundly activates and controls the fibroblast cell functions. Encapsulated in a state-of-the-art, intelligent carrier system, it precisely supports the skin cells natural signaling process for a distinct reanimation of fibroblastic structures. Skin Rebirth.

MEN Oleosome ®

Men Oleosome ® answers all hair and skin problems of modern man. Their skin is different. Tougher, a good quarter thicker than women skin, but also plagued by other problems. Men produce considerably more sweat and sebum than women. Effective, intensive and skin friendly for a calming and soothing effect. Increases the resistance of the skin and makes it feel velvety-soft.

Fragrance Collection ®

MBR® offers luxurious fragrances that encapsulate beauty and allure. L'OR Pure Gold embodies the eternal charm of precious gold. In collaboration with perfumer Marie le Febvre, MBR® Elements offers fragrances that blend artistry with skincare, each with an extraordinary vibe. The Scent of Care line, with its GREEN WHITE, turns skincare rituals into unique experiences, offering a sense of contentment and lightness of being. Experience the world of beauty with the unique scents of MBR®.

Medical Sun Care ®

This effective triple system offers the right protection for every skin type based on the latest findings in medicine and biotechnology. High-quality active ingredients in a special preparation have resulted in products that combine an effective protective function with lasting care and repair properties.

SCIENCE SO PERFECT IT´S Almost Magic

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MBR ® stands for uncompromising quality and is always at the forefront of the latest skincare research and knowledge. Our MBR ® scientists follow a “New Generation” principle, ensuring the “latest and greatest” ingredients, ideas and approaches of skincare are used within our products. We promise to always work in the service of beauty to maintain your youthful appearance.

AND WHAT IS THE PERFECT TREATMENT for You?

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Cream Extraordinary

An intensive, nourishing, and refreshing cream infused with real gold leaf flakes. The synergy of high-level ingredients including advances in medicine, the power of nature with a combination of gold radiance provides remarkable results.

Cream Extraordinary infused with one of the powerful peptide complexes stimulates dermal cell growth and renewal strengthening, regenerating, and rejuvenating the skin from the inside out. The trio of vitamins A, E, and B5 protects from free radicals, enhances cells' vitality, and speeds up recovery.

This multifunctional cream intensively moisturizes the skin and improves the moisture-binding ability significantly reducing and smoothing fine lines and wrinkles.  It stimulates microcirculation, soothes irritation, and promotes collagen synthesis. The surface's structure and texture improved, tone even, and complexion radiant.

Cream Extraordinary comforts and heals even the most sensitive or irritated skin, and ideal weapon against complex dermal issues, aging, or imperfections.

• Promotes collagen synthesis
• Stimulates microcirculation, cell proliferation, and renewal
• The gold particles diffuse light hiding imperfections and wrinkles, illuminating shadows
• Smoothes expression lines, soothes irritation, and firms the skin
• Optimally moisturizes and boosts moisture retaining capacity
• Produces an even, fresh, and natural complexion
• Leaves silky-soft feeling

Apply Cream Extraordinary to the skin and gently massage into with circular movements. After cleansing and serum for the best results. In the morning and/or evening.

It is an excellent plumping cream that lifts and rejuvenates my skin.

This is the one of most effective creams I ever tried. Bought a small one to test. It's amazing, refreshes, and smooths my skin.

Just a perfect cream. Doesn't matter what cleanser or serum used before, always the excellent result.

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MBR - Medical Beauty Research

Nelli Ajrapetova with Mr. Willi Hermann Watkowiak - managing director of MBR.

MBR Jahresfeier

MBR® Medical Beauty Research annual celebration in 2022.

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JSmol Viewer

Searching for beauty and health: aging in women, nutrition, and the secret in telomeres.

Graphical Abstract

1. Introduction

3. the interplay between beauty and health, 4. the aging woman, women: frail and resilient, 5. biological aging: the secret in telomeres, 5.1. sex differences in telomere length and dynamics, 5.2. impact of nutrition on telomere dynamic and health, 5.3. superfoods linked to beauty and health through potential telomere effect, 6. implications and future directions, author contributions, conflicts of interest.

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Share and Cite

Boccardi, V.; Polom, J. Searching for Beauty and Health: Aging in Women, Nutrition, and the Secret in Telomeres. Nutrients 2024 , 16 , 3111. https://doi.org/10.3390/nu16183111

Boccardi V, Polom J. Searching for Beauty and Health: Aging in Women, Nutrition, and the Secret in Telomeres. Nutrients . 2024; 16(18):3111. https://doi.org/10.3390/nu16183111

Boccardi, Virginia, and Joanna Polom. 2024. "Searching for Beauty and Health: Aging in Women, Nutrition, and the Secret in Telomeres" Nutrients 16, no. 18: 3111. https://doi.org/10.3390/nu16183111

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Magic Pigments

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An extraordinarily powerful, targeted skincare cream that penetrates into the deepest layers of your skin. Developed on the basis of MBR ® FibroBoost Complex, an ingredient which has been developed exclusively for MBR ® . With its patented Capsules TM technology and top- class supplementing ingredients, it slows down the ageing process of the skin, visibly reju- venates and opens up a whole new dimension of anti-ageing skincare.

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Here to stay: An attractive future for medical aesthetics

Even at the depths of the COVID-19 pandemic, the future looked bright for the medical-aesthetics industry. As we reported in 2021, the industry was poised to grow by as much as 14 percent annually through 2026. 1 Olivier Leclerc, Nils Peters, Arnold Scaglione, and Joe Waring, “ From extreme to mainstream: The future of aesthetics injectables ,” McKinsey, December 20, 2021. This growth was due to an expanding patient base (thanks in part to increasing awareness and acceptance of aesthetics on social media), a proliferation of outlets providing aesthetic services, the expansion of indications, the adoption of new technologies, and new service delivery channels rising to meet consumer needs.

In 2022, we conducted a comprehensive survey in the United States to assess consumer sentiment and attitudes toward spending on medical aesthetics, particularly in light of the evolving macroeconomic environment. 2 McKinsey Aesthetics Consumer Survey, December 2022. In this article, we draw from the results of that survey and the 2021 article and offer our perspectives on the present state of the medical-aesthetics industry by exploring the following questions:

• How has the market performed over the past two years?
• How resilient is the market, given previous challenges and current economic conditions?
• What are the opportunities for companies and investors?

Recent market trends in medical aesthetics

The market for medical aesthetics in Canada and the United States, which represents an outsize share of the global market, has enjoyed a steady climb since 2019, as illustrated by neuromodulator and dermal filler injectables 3 Vaidruti Joshi, “Aesthetic injectables: Market insights—North America,” Clarivate, October 25, 2023. (Exhibit 1), as well as energy-based devices for facial rejuvenation and hair removal. The market rebounded in 2021 following the dip in 2020 related to the COVID-19 pandemic.

Notably, neuromodulators (such as injectable Botox) have outperformed dermal fillers (such as hyaluronic acid fillers and biostimulators), likely because of higher price sensitivity, given economic uncertainty and competition from alternatives such as fat-grafting and platelet-rich-plasma treatments. Dermal fillers have also seen some backlash about “filler fatigue,” largely focused on hyaluronic acid fillers, 4 Jolene Edgar, “In 2023, will everyone abandon their facial filler?,” Allure , March 24, 2023. which may have resulted in some of the market softening, as well as a relative shift toward biostimulators.

Given the attractive market dynamics, investment activity has continued across the value chain. Private equity acquisitions grew approximately 30 percent per annum from 2019 to 2021, with funds appearing to be executing upon provider roll-up strategies. Deals with a strategic buyer nearly doubled from 2019 to 2021, with providers also adding to their platforms and manufacturers expanding or diversifying their product portfolios. For example, Revance formed an exclusive distribution agreement for TEOXANE dermal fillers in 2020, Allergan acquired Luminera in 2020 for its dermal fillers, and Galderma acquired ALASTIN Skincare in 2022. 5 “Allergan Aesthetics, an AbbVie Company, acquires innovative Luminera dermal filler business,” PR Newswire, October 7, 2020; “Galderma successfully completes acquisition of ALASTIN Skincare®,” Galderma, January 5, 2022; “Revance announces transformative aesthetics portfolio transaction with exclusive U.S. distribution agreement of FDA-approved dermal fillers from TEOXANE SA,” Business Wire, January 10, 2020.

Six trends that portend market resilience for medical aesthetics

The medical-aesthetics industry has demonstrated remarkable resilience over the past two decades. Its performance has tracked the S&P 500’s and even stayed steady relative to the rest of the market during the 2008 financial crisis. The only recent blip was in 2020, when patients had challenges accessing care during the pandemic lockdowns.

Our latest research points to six signs that the medical-aesthetics industry will remain resilient over the medium to long term.

1. Many consumers are still spending; they are just looking for more cost-effective products and treatments

Roughly 60 percent of respondents to the December 2022 McKinsey Aesthetics Consumer Survey expected to spend at least 10 percent less on medical aesthetics should a recession occur. This sentiment appears to have been driven by price sensitivity: nearly half of US consumers (approximately 46 percent) expressed a willingness to switch to lower-price brands or products. Only 7 percent of respondents across the neuromodulator, dermal filler, and facial-rejuvenation segments expected to stop their treatments entirely (Exhibit 2). As more consumers seek treatments from new, lower-cost service-delivery channels—an indication of volume resilience for brands—manufacturers and providers may need to explore innovative go-to-market models to capture these price-sensitive consumers.

2. Even amid financial constraints, many consumers remain brand loyal

Despite a general inclination to reduce spending, some respondents intended to stick with their current brands and treatments, as is the case for 52 percent of consumers who were receiving neuromodulator injections (such as Botox and Dysport). Fewer than 20 percent of respondents across all three categories intended to abandon their current products or treatment plans entirely.

3. An increasingly diverse consumer base is now more open to medical aesthetics

Several technological and societal trends play into the resilience of consumer demand for medical aesthetics and the subsequent growth and evolution of market dynamics. Among them is a widespread and dramatic shift regarding aesthetics and self-image. A market report published in 2022 revealed that 81 percent of consumers are more accepting of noninvasive aesthetic treatments than they were five years ago. 6 Future of aesthetics , Allergan Aesthetics, May 2022. Consumer segments have also expanded and become more diverse. For example, according to American Society of Plastic Surgeons research, between the turn of the century and 2018, 29 percent more males underwent cosmetic procedures overall and 72 percent more opted for minimally invasive procedures. 7 2018 plastic surgery statistics report , American Society of Plastic Surgeons, 2019.

Changes in consumer attitudes and behavior have been mirrored on social media , which has played an increasingly critical role along the full consumer funnel. For example, the American Academy of Facial Plastic and Reconstructive Surgery has noted that social media users are moving from aesthetic treatments to achieve the static “Instagram face” to seeking the more dynamic “TikTok face.” They also reported that 79 percent of facial plastic surgeons agree that consumer demand is increasing for procedures that help them look “better in selfies,” maintain previous procedures, and reduce signs of aging.

4. Manufacturers are innovating to meet growing consumer demand

Technological innovation—including patent filings for next-generation dermal fillers and biostimulators —has risen to meet the needs of an increasingly demanding, diverse, and discerning consumer base. Although the jury is still out on how well they will perform in the market long term, a few recent innovations are addressing some consumers’ most challenging pain points, including the maintenance of neuromodulator injections, the treatment of skin laxity, and severe acne.

Examples of recently approved medical-aesthetic innovations are Revance’s Daxxify and Galderma’s Alluzience, two new neuromodulator formulations; Cytrellis’s ellacor, a nonsurgical skin removal treatment for skin laxity in the mid- to lower face, and Cutera’s AviClear, a laser treatment of mild-to-severe acne. 8 “Cytrellis announces FDA clearance for breakthrough ellacor™ Micro-Coring™ technology, PR Newswire, July 27, 2021; “FDA clears Cutera’s AviClear™ acne device,” Business Wire, March 25, 2022; “Revance announces FDA approval of DAXXIFY™ (daxibotulinumtoxina-lanm) for injection, the first and only peptide-formulated neuromodulator with long-lasting results,” Revance, September 8, 2022.

5. Channel proliferation offers more options to reach a wider array of consumers

Growth in consumer diversity and technological innovations is increasing heterogeneity across channels and provider types. This trend leads to increased complexity and new opportunities for manufacturers and service providers. Results from the global surveys we conducted in 2021 and 2022 provide a picture of channel proliferation.

The surveys also revealed varying levels of consumer loyalty (Exhibit 3). For example, patients of dermatologists were most likely to stick with their provider, who could leverage these trust-based relationships to broaden customers’ access to a range of aesthetic treatments. Meanwhile, fast-expanding medical spas and aesthetic clinics offer appealing options for shoppers seeking promotions and discounts, but their customers were less loyal than those treated by individual practitioners.

In such a fragmented provider landscape, manufacturers and service providers can implement tailored go-to-market strategies that blend traditional, higher-cost methods for consumer activation and retention with digitally enabled, more consumer-centric models that cater to new consumer segments and drive loyalty. Using advanced analytics or AI for customer insights and microsegmentation, companies can target specific consumer groups, understand their unmet needs, and adapt pricing dynamically. And although some services, such as injectables, will continue to be delivered in person, an increasing number of treatments, including at-home skincare and hair removal, are available through a hybrid model that includes robust online channels.

6. The market remains underpenetrated

Our analysis across all medical-aesthetics product segments indicates a high number of “fence sitters”—consumers who say they will try a product or treatment within the next five years, specifically including the next 12 months. Fence sitters are an important indicator of future growth potential in an industry.

When we compared fence-sitting data in the 2021 and 2022 surveys, we observed that the phenomenon remained unaffected by significant changes in the macroeconomic environment in the latter year—and in some cases, the trend is even more promising.

For example, in 2021, we found that 15 to 20 percent of respondents intended to use injectables (neuromodulators and dermal fillers) within the next five years, which would double the number of survey respondents who currently used those products at the time of the survey. Our 2022 findings (Exhibit 4) were consistent with those results. However, taking a closer look at the dermal filler segment, we noted that just as many respondents who hadn’t used dermal fillers recently intended to do so in the next 12 months. And looking ahead to five years, 11 percent of respondents said they intended to use dermal fillers, which would triple the number of current users at the time of the survey.

Opportunities for investors and companies in medical aesthetics

Despite the current uncertain macroeconomic climate, our research indicates that now could be an opportune time to capitalize on current and projected consumer demand for medical aesthetics and invest in innovations. Our previous analysis showed that healthcare manufacturers and providers that innovate during a crisis  (such as the COVID-19 pandemic) and maintain their focus on growth and rapid adaptability tend to outperform the competition.

As medical-aesthetics channels continue to expand, investors may consider consolidating regional and local providers to create national and global chains to drive revenue and cost synergies through cross-sell and standardized operations.

And as consumer bases expand, providers could optimize the mix of products and treatments to include surgical aesthetics and at-home offerings, considering evolving preferences and the mixed effects of GLP-1 agonists. New business models, like subscriptions for neuromodulators and devices for facial rejuvenation, also present growth opportunities.

Opportunities also exist for manufacturers to advance consumer funnel management, value-based pricing, and digital engagement to educate providers and boost loyalty. Product innovations such as injectable exosomes and intradermally delivered mRNA for collagen replacement therapy can penetrate into new segments and boost market value. But they also pose a risk of cannibalizing current products, and their success will depend on the go-to-market strategy and on consumer adoption patterns.

Leigh Jansen is a partner in McKinsey’s Boston office, Olivier Leclerc is a senior partner in the Southern California office, and Nils Peters is a senior partner in the Zurich office.

The authors wish to thank Dimpy Jindal and Joe Waring for their contributions to this article.

This article was edited by Jermey Matthews, an editor in the Boston office.

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For much of the 20th century, Russian medicine was cut off from the international scientific community by the isolation of the Cold War. As it begins in earnest to reconnect, a Yale collaboration in Tatarstan is helping to break down old bariers. A letter from Kazan.

Beneath a portrait of a.f. agafonov, founder of kazan’s infectious disease hospital, diljara enaleeva gives a lecture to medical students on pediatric infectious diseases., russia illustration, most large cities in russia have their own kremlin, a citadel and seat of government power. from the gates of the kremlin in kazan, a view of the republic of tatarstan’s state museum., above and below michael david, one of many yale residents to spend time in kazan, offers a class in evidence-based medicine to russian residents. , arsen kourbangaleev made his own video to teach the laparascopic surgical techniques he observed while at yale., kazan state medical university was founded in 1814, the year that yale’s medical school conferred its first degrees, and has 5,000 students., an attending physician leads residents in rounds at kazan’s infectious disease hospital., russian and american doctors cemented their friendship and collaboration with meals and toasts., physician jeffrey wong has visited kazan three times to train academic physicians to become better teachers., on his first visit to kazan, asghar rastegar, associate chair of internal medicine at yale, sensed a deep desire for change., the energy of young doctors and students in kazan led yale physician majid sadigh to join rastegar in proposing the exchange., nail amirov, rector of the medical school in kazan, looks to yale and other international institutions to help advance medicine in tatarstan., adelia maxudova, one of the first russians to participate in the exchange, is now an assistant professor at the medical school in kazan. she has a deep commitment to russian medicine and remains a passionate supporter of the international program., for diana nurutdinova, who is spending three years at yale as a resident, the international collaboration offered a chance to go home to kazan for a visit. while in kazan she stayed with her parents, yuri sololov and raisa iskhakova, and got reacquainted with her cat, kotya, and dog, manya. nurutdinova plans to return to kazan to practice medicine after she completes her training in infectious diseases., alexei sozinov, deputy rector at the medical school in kazan, understands physicians who wish to seek opportunities abroad. the nation’s goal, he says, is to create an environment that will make them want to stay., physician dmitri tarassevitch, one of the participants in the yale exchange, wants to take part in international medical programs before he settles down in russia..

To appreciate the sea change under way at Kazan State Medical University, one needs a swift history lesson, a tour of the 189-year-old school that shows what this seat of learning once was and what it hopes to be. A good place to start is inside the wood-paneled anatomy theater, where 19th-century instructors dissected cadavers before audiences of medical students (and the occasional Russian aristocrat permitted to watch from the balcony above). Around the room, glass display cases hold dozens of jars containing organs, limbs and fetuses, a collection of odd specimens that once belonged to Peter the Great.

Down the hall in a classroom, students wearing white caps and lab coats study under a mural depicting great healers from antiquity alongside esteemed medical professors from 19th-century Kazan. The painting shows men standing around a cadaver, those on the left side wearing ancient robes and turbans. Among them are Ibn Sina, the 11th-century Iranian philosopher who wrote The Canon of Medicine , and Galen, the ancient Greek who first diagnosed a patient by taking a pulse. There’s Nikolai Ivanovich Pirogov, the Russian scientist famous for developments in battlefield medicine during the Crimean War, and next to him are three former chiefs of the Kazan anatomy faculty: Aristov, Tankov and Lesgaft.

These pieces of art and artifact testify to a long and substantial history and an era when the medical school was internationally renowned. “In 1880, Russian science was at the level of all Europe,” says Valerii Albitski, M.D., Ph.D., chief of the university’s department of medical ethics, history and law. He is standing across campus in the school’s museum, which also pays homage to this chapter in Russian history. The walls are lined with the portraits of scientists and physicians from a prerevolutionary epoch when Russian doctors led many of their fields. Ivan Petrovich Pavlov won the Nobel Prize in 1904 for his research on the effects of the nervous system on the gastrointestinal tract, and Ilya Illyich Mechnikov’s work on the immune system earned him the Nobel four years later. The hero claimed by the city of Kazan, a metropolis of 1.1 million inhabitants 450 miles east of Moscow, is Alexandr Vasilyevich Vishnevski, who in the 1920s played a major role in advancing techniques for administering local anesthesia. He eventually became the Kazan medical school’s rector, or dean, and his statue—along with those of Lenin and the writer Pushkin—stands on the sprawling city campus of large, Soviet-era buildings.

Russian medicine changed after the fall of the czars and the sealing off of the Soviet Union that began under Stalin and continued through most of the 20th century. Like other institutions, Kazan’s medical school became isolated from international dialogue, and nearly a century after social and political revolution began fermenting in the old Russia, Russian medicine is still recovering from its aftereffects. “It’s something of a Russian curse,” says historian Albitski, “that we have to remake ourselves every 100 years.”

While the paranoia of the Cold War did much to drive scientific achievement in fields crucial to the arms and space races, it also had the effect of curtailing inquiry that depended on scientific exchange with the West. The enormous social changes—the abolition of class-driven wealth and status, the equalizing of professions—meant less funding for established Russian institutions, including those that had supported medical research. Today, the physical environment of Kazan’s medical university wears the scars of those years of deprivation. The dignified buildings of the rambling campus are dim and grimy from lack of maintenance. Students wear thick sweaters under their white lab coats. The heat is not on, even though it is early October and snowing. But step inside the classroom of surgery professor Arsen Kourbangaleev, M.D., and you’ll see part of the latest “remaking” the historian is talking about.

It’s showtime

Kourbangaleev, a lanky, soft-spoken man with a bushy moustache, hits the play button on a VCR, then appears on the screen dressed in green scrubs, sitting behind a desk and speaking in Russian. Soon, the image changes to the tiny blades of a laparoscopic instrument snipping away at fatty tissue. The procedure is the nephrectomy portion of a kidney transplant, and the video—a routine teaching tool for doctors in the United States—provides the first glimpse of laparoscopic surgery for many students in the classroom. Kourbangaleev learned laparoscopic technique after spending several months as an observer in New Haven three years ago, and made his own video on his return home with footage shot at Yale. The tape lasts only 30 minutes but it represents several decades of technological catching up with Western colleagues and a big step forward in the institution’s efforts to rejoin the international medical community at full speed.

Kazan State Medical University was founded in 1814, the same year Yale conferred its first medical degrees. It has a student body of 5,000, encompassing medicine, nursing, pharmacy, dentistry and social work, and a faculty of 650. (By comparison, Yale has 507 medical students and 1,330 full-time medical faculty members, many of whom are engaged primarily in basic research or clinical care, rather than teaching.) Medical education in Russia begins after secondary school and lasts six years.

Eager since the fall of communism to regain its previous status, Kazan’s medical university has been active in seeking connections with the West. Kazan faculty have research affiliations with several European institutions, in particular the Catholic University of Leuven, in Belgium, and the medical school is working on setting up a program with East Carolina University, in Greenville, N.C. But Kazan’s exchange with Yale is the main one, because it has continued for so long and is open-ended. For the past five years, Yale faculty and residents have gone to Kazan every year, and Kazan professors have come to New Haven and nearby Waterbury, Conn.

So far 30 Russians have come here, and 20 faculty members, residents and students from Yale, along with several administrators from St. Mary’s Hospital in Waterbury, have gone to Kazan. The most recent visitors from Russia included a neurologist, an infectious disease specialist and two obstetrician-gynecologists, each of whom spent several months last fall following mentors at St. Mary’s and Yale-New Haven hospitals and meeting with Yale faculty and house staff. Also this year, the School of Public Health became involved in the Kazan exchange and sponsored a faculty member from Kazan who is spending a year in New Haven.

Among those traveling from Yale to Kazan last fall was Jeffrey G. Wong, M.D., an associate clinical professor of medicine, who gave seminars designed to turn good physicians into good teachers. His trip in September was his third in two years. He was joined by two Yale residents in internal medicine, Michael Z. David, M.D., a resident physician and doctoral candidate researching the history of tuberculosis and its treatment in Russia, and Diana Nurutdinova, M.D., a native of Kazan who came to Yale on the exchange in 1998 and returned to New Haven two years later to continue her training in internal medicine and infectious diseases. David and Nurutdinova conducted research into the social history of patients at a tuberculosis hospital, poring over files to determine, for example, if they were smokers or HIV-positive.

They also taught a class in evidence-based medicine, an emerging field based in part on concepts developed at Yale by the late Alvan R. Feinstein, M.D. In the course, residents from Kazan learn how to formulate a clinical question, find relevant data by searching the medical literature, evaluate the data and make clinical decisions based on the best available evidence. Although the scarcity of medical journals in Kazan has been a major obstacle to the project, Yale’s help in providing a small reference library and 11 computers with Internet access has made a large difference. Another focus of the exchange has been to establish team-based teaching on the wards for students and residents in Kazan, where clinical instruction is mostly classroom-based with little input from practicing physicians.

The program’s success reflects a warmth among the participants that has grown over the past decade, says Asghar Rastegar, M.D., one of its main architects and Yale’s associate chair of medicine. A visitor to Kazan is wined and dined, whisked to the ballet and museums and taken on outings down the Volga River or to the 17th-century monastery at Raifa. On this end, Russians spend considerable time with the Yale professors in New Haven and Waterbury and sometimes live with a faculty member during their stay. The socializing that goes on helps foster a trust that eases communication between members of two very different cultures.

“It’s very important that our program with Yale is ongoing, because that means it works,” says Nail Amirov, M.D., the Kazan medical school’s rector. “Isolated visits of just one month wouldn’t work, but over time, this has showed the advantage of what can be taken from the American system.”

What can be taken, says Amirov, are strategies for better medical training. By seeing the American medical system firsthand, Kazan’s faculty members fully grasp developments the Russian medical system missed during the Communist era. Further fueling the need to make up for lost time is the pace of social change in Russia. A growing consumer culture, the spread of information via the Internet and rising standards of living mean that Russian people want, and demand, more from their doctors—though there remains a sizable gap in expectations (See sidebar ). Private insurance is on the horizon, and people with money can go abroad for operations. Kazan, the capital of Tatarstan and a center of Russian culture and history—where the dramatist Maxim Gorky came of age, where Tolstoy and Lenin studied, where Nureyev danced—is relying on Yale and other international contacts to speed its development in medicine. “Fifteen years ago, this would have been impossible to imagine,” the rector adds. “Back then, there was total isolation.”

A cultural crossroads

The seeds of the Yale-Kazan program were planted in 1992, when Yale residents and faculty in internal medicine began participating in a program, funded by the U.S. Agency for International Development, to help modernize the former Soviet medical system. The grant, managed by the University of Rochester School of Medicine, enabled visits by American academics to 13 schools in Russia, Ukraine and Belarus. Representing Yale was Asghar Rastegar.

Rastegar, a nephrologist who joined the Yale faculty in 1985, had long wanted to visit the country that produced the literature of Dostoevsky and Tolstoy. In Kazan, he found a city rich in history and a culture shaped by a melding of European and Asian influences. Located near the confluence of the Volga and Kama rivers 600 miles north of the Caspian Sea, Kazan marks a crossroads of East and West. Its prehistoric settlements date back 100,000 years; modern habitation began in the eighth century when members of the ancient Bulgar tribes began to populate the Volga valley. Islam became the state religion in the 10th century and remained dominant until the invasion by Ivan the Terrible in 1552. But unlike the situation in the Caucasus 900 miles to the south, where Chechen rebels and Russia’s military are fighting a brutal and protracted war, Tatarstan’s ethnic groups have enjoyed a mostly harmonious coexistence for centuries. Forty-nine percent of the population of the Federal Republic of Tatarstan—one of 21 republics in the Russian Federation—is ethnic Tatar, a predominantly Muslim people who migrated to the region from the east. Most of the remainder, 43 percent, is Russian, with a tradition that is mainly Slavic and Christian. The tight interweaving of these two groups is apparent throughout the city, in a skyline punctuated by the crescent moon of Islam atop minarets, in the onion domes of Russian Orthodox churches and the city’s Kremlin (a sprawling, walled government complex that soon will be 1,000 years old) and in the faces of its people. All this, along with the city’s role as an active river port, creates a cosmopolitan setting that extends to the medical school.

“Out of all my contacts in Russia, Kazan was the only place where I sensed a clear desire for change,” Rastegar recalls during an interview in his office in New Haven. “It wasn’t expressed openly, but I sensed their desire to become what they were in the last part of the 19th century. They are very proud of what they were. I got that feeling in my meeting with the rector. All the other rectors in the other medical schools tended to be very formal, and they never moved on to the more personal questioning of ‘Why are you doing this and what are you interested in?’ These questions opened up the conversation to a different level.”

A native of the ancient city of Shíraz in southwestern Iran, Rastegar has an easy charm and a gift for diplomacy. And his own history has given him empathy for people who have experienced political upheaval. After getting his medical degree at the University of Wisconsin and training at Penn in medicine and nephrology, Rastegar returned to Iran in 1973 and taught at Shíraz’s medical school. He spent a sabbatical year at Yale in 1976-77 and returned home just in time for the start of the Islamic revolution that toppled the Shah and laid the foundation for the country’s current political climate. Rastegar was expelled from his teaching job and briefly imprisoned for his activism for democracy. He left the country in 1983, settling at Yale two years later.

Lessons from the East

While a professor in Iran, Rastegar participated in several faculty and resident exchanges with Western institutions, including Yale. He saw how such projects could founder on cultural misunderstandings if the Western partner tried to impose its values or methods without consideration for the country it was trying to help. “One needs to make sure that advice is filtered through the reality of life,” he says. “In my contacts with Kazan, I was very conscious that they are the ones who are going to solve their problems. But having contact with the best institutions abroad can energize the process of change.”

So Rastegar began thinking about how an exchange could work. In 1997, he asked his Yale colleague Majid Sadigh, M.D., to go to Kazan. Sadigh, an associate professor of medicine, had been Rastegar’s student and resident in Iran and experienced similar repression before coming to the United States. “Dr. Sadigh went [to Kazan] out of curiosity, with no expectations,” says Rastegar. “He was captured by the phenomenal energy of the young people in Kazan and said, ‘Let’s do it.’ ”

Together, the two men hashed out the beginnings of the exchange proposal. The program grew with help from St. Mary’s Hospital in Waterbury, which chipped in room, board and funding for travel for the Russians; Yale has provided books, journals and computer expertise to the medical university. Financial support for the exchange has come from individuals and organizations including the Waterbury Medical Society and the Jewish Federation of Waterbury. Yale’s International Health Program has helped support Yale residents who choose to spend time in Kazan as part of their training. Rastegar will make his fifth trip to Kazan in June with Yale colleague Fredric O. Finkelstein, M.D., to lead the city’s first international nephrology conference.

The direction in which much of the knowledge has been flowing during the initial years has been from west to east. But Rastegar sees many opportunities for American doctors to learn from their Russian and Tatar colleagues. The time-capsule effect of the Soviet era left intact systems of alternative medicine as well as a network of sanitoria used for rehabilitative medicine. Sick people in Russia often travel to the countryside to convalesce for weeks at a time, a therapeutic approach unthinkable under American managed care. “Their rehabilitation is much more holistic than ours,” says Rastegar. “This area is fascinating to me, and there’s no data on this yet to show.” All it takes is for someone to get interested, he says, and the exchange program will adapt. With a core goal of “change through education,” as Rastegar defines it, the Yale-Kazan project is wide open for whatever participants want to do, on either side.

Kourbangaleev, the surgeon who came over in 2000 as an observer, is a good example. “He really used his time here,” says Rastegar. “We brought him here to learn how surgery is taught” on a basic level, but Kourbangaleev expanded the scope of his training to include laparoscopic procedures, and he now teaches those advanced methods at home with the help of the videos he made. “This was not the objective of the program,” Rastegar says. “But that’s what happens.”

A different mentality

For now, the changes in Kazan are at a grass-roots level. Everyone, from the rector to the hospital residents, says the medical system needs to change, but the system is still centralized and any significant change would require support on the federal level. Hence, the Yale influence in Kazan has much to do with changes in attitude. That involves encouraging doctors and students to trust their judgment, think for themselves and not rely only on tradition and business-as-usual. Resident Michael David describes the goal of evidence-based medicine this way: “As a doctor, you “should always be curious, you should always be skeptical. You should always be conscious of what you’re reading, where the source is. Never accept things blindly, which is the way many are taught to practice medicine. What we’re teaching is a new mentality, a new approach to medical epistemology.”

Another facet is expressing that independence of thought. This is rather radical in Russia, where medical education is largely based on a 19th-century German model in which the teacher is the ultimate authority. That history, plus the legacy of the Soviet era, means Russian medical students tend to keep their heads down. Even getting professors to speak up is a major hurdle, says Wong, the Yale faculty member whose course on teaching techniques relies on class participation and role-playing. But once they start participating, the professors seem to love it. “I’ve never experienced such teaching,” says Yudina Guzel, M.D., Ph.D., a lecturer in dentistry. “He talks to us like we’re his equals. This is the way all teaching should be.”

At one of the many dinners Wong attended during his stay, he raised his glass to the Kazan professors. “It’s fairly difficult to imagine how to change what you’ve always been told to do,” he told his Tatar and Russian hosts. “So I think it’s very exciting that Kazan has started to make this step to be very progressive.” Still, there remain differences between the American and Russian medical systems that no amount of cross-cultural goodwill can overcome.

Start with money. The medical system in Russia has little of it, and Russian doctors’ salaries are a pittance compared with what U.S. doctors make. At a little under $100 a month, they provide barely enough to live on, much less buy a car or a house. The equipment at Kazan hospitals varies wildly. The No. 1 Republican Hospital, which serves all of Tatarstan, population 3.7 million, has only one MRI machine and one CT scanner. Meanwhile, across town, the Interregional Diagnostic Center has the latest state-of-the-art equipment, including a room for telemedicine conferences, but part of the building is still under construction.

And in a climate where entrepreneurs seem to have all the cash, some Russian doctors are abandoning medicine. Adelia Maxudova, M.D., assistant professor, has a car because her brother bought it for her. He left medicine to open a laser eye surgery clinic. Once he achieved financial security, he became the administrator of an ophthalmology clinic. But he does not practice medicine. Maxudova was in the first wave of Russians coming to Yale, and because of her time in New Haven she decided to specialize in nephrology. She is a passionate doctor and a passionate booster of the Yale exchange, yet she is frustrated with teaching. Some students at the Kazan medical school, she says, have no intention of actually becoming doctors. Because medical school starts after high school here, a medical degree in Russia can be like a U.S. undergraduate degree—a ticket to a profession that has nothing to do with your major.

“I get very upset about this sometimes,” says Maxudova, sipping coffee in a Kazan café. “Often I talk to someone who says, ‘My daughter wants to be a doctor.’ I say: ‘Do you realize what your child is going to make on a doctor’s salary?’ Under Soviet times, nobody was rich. Everybody was the same. Now the salary is so small. But the profession is still very prestigious.”

So being a doctor in Russia is a labor of love: there’s respect, but not much money. And it raises the touchy problem of whether Russian doctors who come to the United States via Yale will want to return to Russia. Rastegar says the program takes care to pick Russians who have compelling ties to home—young people in the middle of fellowships, faculty members with prestigious positions or strong family connections. Participants have an unspoken contract with Yale not to exploit the exchange and a written contract with the university to return to Russia and work for at least three years. No one has broken that pledge to date, perhaps in part because of the way many of the physicians in Kazan regard a life in medicine in the United States. As one of the residents visiting Yale from Russia this winter put it, she would gladly live without a higher salary and access to modern medical technology in order to retain the strong family and community ties she has in Kazan.

Bringing it home

Yale resident Nurutdinova plans to bring some of the best of American medicine back to Kazan when she returns after completing a fellowship in infectious diseases. After graduating from medical school there in 1996, she started a residency in internal medicine (infectious diseases). Two years later, she visited Yale as part of the exchange program. Back in Kazan, she realized she wanted the more general medical training available in the United States. (In Russia, she says, medical students specialize quickly. “And my specialty is so broad-based, I need to know medicine really well.”) “A residency in the United States is a really good opportunity to become a better physician,” she says. So Nurutdinova took steps 1 and 2 of the United States Medical Licensing Examination at great expense and effort, applied to Yale’s internal medicine residency program and got in. She’ll complete the program in June at age 29.

After more than two years in New Haven, her trip back to Kazan in September for tuberculosis research was a welcome chance to see her family. Her next goal is to secure a fellowship at an American hospital where she can learn to write grants. But she plans to return to Kazan to do research on HIV/AIDS, a growing problem in Tatarstan. “You have to go to the United States and stay there for some time to realize the place you belong to is home,” she said during her visit to Kazan. “I had this first surge of thinking that maybe I should stay in the United States. But I’m not going to be useful by staying there. That’s not going to make sense with what I want to do with my life. Besides, I miss my family so much.”

Another Yale exchange alumnus, urologist Dmitri Tarassevitch, M.D., wants to follow a similar path, at least the part that takes him back to the United States for a residency. But he is less tied to home. Reflecting on his goals in an e-mail, Tarassevitch described his frustration with Russia’s lack of funding, good medical equipment and up-to-date research. His goals are wide-ranging. He hopes to participate in international programs, like those of Doctors Without Borders. And he, too, wants to settle in Russia—eventually. “I love my country, my people, teachers, friends, colleagues,” he wrote. “The problems and needs of Russia are too familiar to ignore them. I would love to serve people and to know that people need me. But I would also like to be a man of the globe, not to confine myself to a narrow region with borderlines. Doctors must be like that, I believe.”

Sitting at his desk in Kazan, deputy rector Alexei Sozinov, M.D., an associate professor of infectious diseases, is well aware of the potential for brain drain. He says he understands and accepts that students will be attracted to opportunities abroad. “It’s life,” he says. “Everyone wants to have a good life. And the residencies in the United States are the best in the world.” More troubling is the potential loss of faculty. In the physiology department, for example, about 10 professors have left for the United States and Europe. But despite the risk of losing other faculty members, his commitment to international programs is strong, evidenced by his animated tone—not to mention the large collection of mugs from around the world that decorates his office. For one thing, the exchange of ideas and people will make Kazan State Medical University a stronger institution and a more desirable place to teach, study and do research.

Sozinov told a story: “Several months ago, President Putin met in St. Petersburg with students. Russian students asked him this very question about the problem of young, talented Russians wanting to get out. Putin says, ‘Of course, we’re concerned that young people with good educations are going to leave the country. It’s a real loss, and it’s even an economic loss. But we’ll never use old measures to stop this process. We’ll never close the country. Our goal is to make life in Russia much better so that doctors and teachers will want to stay here.’ And I share these ideas 100 percent. I have the same point of view.” YM

• Internal Medicine

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• Fredric Finkelstein
• Asghar Rastegar, MD Professor Emeritus of Medicine; Founding Director of Office of Global Health; Senior Research Scientist, Internal Medicine

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• v.108(1); Jan-Feb 2011

Cosmeceuticals: The New Medicine of Beauty

Cosmeceuticals represent a new category of products placed between cosmetics and pharmaceuticals that are intended for the enhancement of both the health and beauty of skin. Encompassing an ever-increasing part of the skin care industry, cosmeceuticals are formulated from a multitude of ingredients, the main categories of which are discussed in this article. Given the growing interest in these products among patients and the strong claims made by manufacturers, it is important that physicians recognize these agents and understand their benefits, limitations, and potential adverse effects.

Introduction

The American population is becoming older and more affluent than ever. With many people willing to trade wealth for youth, there has been a surge in demand for high-end anti-aging products, and the skin care industry has responded in force. Moving beyond traditional cosmetics—which only temporarily adorn and beautify the skin—cosmetics companies have tapped into the biomedical revolution, adding biologically active ingredients to their products that enhance the function of healthy skin. Because these products are not intended to improve or to cure diseased skin, they have avoided pharmaceutical regulation and scrutiny. Thus, “cosmeceuticals” blur the line between drug and cosmetic, doctor and aesthetician, and patient and consumer.

Patients can flounder in the flood of new products, finding it difficult to select the right product and becoming frustrated when a product fails to produce its beneficent effect. Patients remain enthusiastic about these products, however, and seek their physician’s help in choosing the best products available. Physicians educated in these cosmeceuticals can serve their patients by (1) managing expectations to realistic, evidence-based effects and (2) warning against and monitoring for potential side effects.

There remains much controversy surrounding the “active ingredients” found within cosmeceutical products, particularly in regards to their mechanism of action, formulation, optimal concentration, penetration and retention in skin. Some clinical trials and tests have been done to address these questions, but on the whole there is little validation to support cosmeceutical claims. In vitro testing for some products has shown that these ingredients do have a protective and repairing effect on aging skin; however, there has been little translation of this evidence into in vivo testing to determine the possibility of delivering adequate doses to skin that will produce clinical or histologic results. 1

Many cosmeceutical agents are developed and advertised for prevention and treatment of aging skin, particularly photoaging skin. Photoaging refers to the damage that is done to the skin from prolonged exposure, over a person’s lifetime, to solar UV radiation. While the most important protective measure against photoaged skin is the daily application of UVA and UVB sunscreen, potential treatment options for already damaged skin involve the use of topical antioxidants and compounds that help repair DNA and stimulate collagen synthesis. Topical vitamins are substances that are purported to provide some of these benefits.

The efficacy of topical synthetic Vitamin A or retinoids—in various forms such as tretinoin, adapalene, and tazarotene—is evidence-based, and the cosmetic benefits of these prescription retinoids are well supported by ample research. 2 , 3 Tretinoin induces production of type I and II procollagen in skin and reduces collagen breakdown by inhibiting metalloproteinases. The overall effect is a thickening of the dermis as the skin is “filled in” with glycosaminoglycans, helping to reduce fine lines and wrinkles.

Other retinoids, such as retinaldehyde, retinol, and the retinyl esters, are marketed as over-the-counter cosmeceuticals and may have similar actions to their prescription counterparts despite having less evidence proving their efficacy. 1 Patients should be cautioned that all of the retinoids are able to produce skin irritation and dryness, even in over-the-counter formulations, although the latter much less than prescription-strength products.

Vitamin E is another vitamin that is purported to have advantageous cosmetic effects on skin. Functioning as an epidermal antioxidant by absorbing the solar spectrum of UV light, endogenous Vitamin E becomes depleted after years of excessive exposure to free radicals, with resulting oxidative damage. Thus, many studies have looked at the benefit of applying topical Vitamin E, especially in its most active form alpha-tocopherol, as a means of protecting against sunburn and improving the wrinkling and hyperpigmentation caused by free radicals. Studies in human subjects have demonstrated its efficacy in preventing UV-induced skin erythema, with topical 2% Vitamin E reducing the redness value by approximately 20%. 4 A four-month facial study of topical 5% vitamin E resulted in improved wrinkling and UV-caused inflammation around the eye area. 5 Importantly, Vitamin E can reduce UV-associated erythema and edema when applied before UV exposure, with little benefit noted if Vitamin E is applied after the exposure. 6 Also, almost no side effects have been reported from the use of topically applied vitamin E.

One of the most recently recognized “cosmeceutical vitamins” is Vitamin B 3 , also called nicotinamide or niacinamide. A precursor to the key metabolic cofactor NAD(P) and its powerful reduced form NAD(P) H, niacinamide’s role as a key player in antioxidizing reactions has been the focus of most of the studies. Well-tolerated in topical form, niacinamide has been shown to improve skin barrier by increasing lipids and epidermal protein. 7 This action leaves skin more resistant to irritation and blotchiness, most likely by decreasing water loss from skin. Niacinamide also reduces facial dyspigmentation via a mechanism that inhibits melanosome transfer from melanocytes to keratinocytes. 8 Other beneficial effects with chronic topical niacinamide application include improvement and prevention of skin yellowing and a smoothing of skin texture. However, even with these benefits, topical niacinamide remains one-third to one-fifth as effective as topical 0.025% tretinoin. 9

Vitamin C, also known as L-ascorbic acid, is one of the vitamins that humans must obtain from dietary sources. However, oral supplementation of Vitamin C only minimally increases its concentration in skin. Thus, topical Vitamin C application is a popular research area. In addition to its well-known and essential contribution to collagen biosynthesis, research data demonstrates that topical Vitamin C has anti-inflammatory and antioxidant properties, 10 such that it has been used to reduce the erythema associated with postoperative laser resurfacing. A double-blind, placebo-controlled, splitface 12-week study examining the effects of topical 3% ascorbic acid showed that Vitamin C is well-tolerated in topical application and causes a reduction in facial wrinkles. 11 Higher doses of 5–17% ascorbic acid revealed improved skin texture and the appearance of photoaging. With ongoing research confirming and maximizing the benefits of topical Vitamin C and the other cosmeceutical vitamins, these agents will continue to grow in their usefulness and value in protection and restoration of skin.

Hydroxy Acids

The hydroxyacids—comprised of the α-hydroxyacids, β-hydroxyacids, polyhydroxyacids, and bionic acids—represent a class of compounds with unprecedented cosmetic benefits. The most well-known and commonly used is the α-hydroxyacid glycolic acid for its proven antiaging benefit and ability to improve hyperpigmentation and acne-prone skin. Both the α-hydroxyacids and β-hydroxyacids work by removing or decreasing hyperkeratinized skin and restoring the epidermis, making them useful for treatment of dry skin, verrucous growths, and ichthyosis. 12 Furthermore, application of hydroxyacids causes dermal thickening by stimulating biosynthesis of glycosaminoglycans, collagen, and elastic fibers, improving wrinkles and fine lines. 13 The polyhydroxyacids and bionic acids are newer agents with the same benefits as the α-and β-hydroxyacids but without their characteristic irritation or burning and with additional antioxidant and barrier functions to improve moisturization. Their gentleness on skin makes them ideal for treating sensitive skin. Gluconolactone is a polyhydroxyacid widely used in skin care products that has been shown in vitro to protect against UV radiation by trapping free radicals. 14 The hydroxyacids, especially glycolic and lactic acid, are commonly used as peeling agents. Applied to the skin in high concentrations for short periods of time, hydroxyacid peels are increasingly used to accelerate exfoliation and to stimulate skin renewal to improve hyperpigmentation and texture of skin.

The role of peptides in cosmeceuticals revolves around the hypothesis that peptide fragments of collagen and elastin can act as positive feedback signals for their own continued synthesis. Peptides are highly successful in the current cosmeceutical market, and there are increasing numbers of double-blinded, placebo-controlled studies to examine their effects on human skin. Peptides of interest include pal-KTTKS (Matrixyl), Ac-EEMQRR (Argireline), and Cu-GHK. The peptide pal-KTTKS is a fragment of dermal collagen that stimulates new collagen synthesis in vitro and is postulated to facilitate wound healing. 15 It has high potency and was shown to improve wrinkled skin when applied topically at very low doses and with minimal skin irritation. Cu-GHK is also a fragment of dermal collagen, and the copper moiety is a necessary cofactor for collagen synthesis. Many peptides, such as Ac-EEMQRR, mimic botulinum toxin and function to cause muscle relaxation by inhibiting neurotransmitter release; 16 however, a 2006 study comparing topical nonprescription products, including those containing peptides, to botulinum toxin type A injections concluded that the injections provided significantly greater efficacy and patient satisfaction in the treatment of glabellar frown lines. 17 The cost of all of these peptides remains a challenge to cosmeceutical companies, especially if the peptide has low potency and requires greater concentrations to achieve efficacy.

Growth factors

Growth factors function as regulatory proteins that mediate signaling pathways, particularly those associated with wound healing. Kinetin, also known as N-6 furfuryladenine, is a plant growth factor studied in human skin fibroblast cultures. In vitro studies have demonstrated that the continuous application of kinetin may have the ability to delay the skin changes associated with aging as well as decrease the severity of these changes. Kinetin prevents the alteration in cell size and shape and delays growth rates and macromolecular synthesis associated with aging. Kinetin acts as both an inhibitor of free radical formation and a scavenger of reactive oxygen species by mimicking superoxide dismutase. Other clinical studies have suggested that topical kinetin may improve skin texture, decrease hyperpigmentation, and impede transepidermal water loss, but the mechanisms for these actions have much less evidence to support them. 18

Cosmeceutical agents derived from plant sources make up an increasing niche in the cosmetic market. A huge variety of botanical products exists, and many claims are made regarding their dermatologic benefits; however, few studies have been conducted to substantiate these claims and examine the safety and efficacy of these ingredients.

Among these botanical substances, Ginkgo biloba, silymarin, ginseng, soy, and green tea have exhibited capacity to promote skin health and appearance. Ginkgo biloba is a common botanical added to moisturizers for its anti-inflammatory and antioxidant properties.

Although no controlled trials exist regarding the cutaneous benefits of Ginkgo biloba, studies carried out in vitro have shown that topical G. biloba extracts stimulate fibroblast proliferation and collagen synthesis. 19 Silibinin, or silymarin, is a phytochemical from the milk thistle plant Silybum marianum that exhibits strong antioxidant activity and has been shown in various studies to neutralize toxic effects of different chemicals and UVB radiation in skin. 20 Ginseng is another botanical that has demonstrated significant dermatologic potential when applied topically, with the apparent action of reversing the manifestations of decreased hyaluronan levels that occurs with aging; other in vitro studies show that ginseng extracts have the ability to inhibit melanogenesis in melanoma cells, suggesting a possible role as a depigmentation or whitening agent for skin. 21

Soy and its isoflavones have been purported to have a variety of dermatologic benefits, many of which are ascribed to its antioxidant effects and the estrogen-type action of its metabolites. Its phytoestrogen effect is thought to be mediated by binding to estrogen receptors in the cell’s nucleus, potentially slowing the skin thinning and collagen loss that occurs post-menopause. Soybean protease inhibitors and soy milk have been found to have depigmenting activity as well as the ability to reverse UV-induced hyperpigmentation. 22 Lastly, green tea polyphenols are being aggressively marketed for their antioxidant and anti-inflammatory properties, which include limiting UV-induced lipid peroxidation in vitro. 23 There is also evidence that green tea polyphenols inhibit the activity of collagenase and increase biosynthesis of collagen in human fibroblasts.

Thus, all of the above botanical cosmeceuticals have been shown to influence mechanisms on skin that repair or prevent aging effects. For many of these products, however, there has yet to be a split-face, double-blind, randomized trial involving different concentrations of these ingredients and reporting side effects on which to base recommendations for use of these products.

Cosmeceuticals offer both challenges and rewards to patients and their physicians. As society holds a youthful and healthy appearance to be of utmost importance, many people feel anxious about their aging skin and seek physician advice on what to do.

Helping patients understand the degree of improvement that can realistically be achieved as well as potential side effects remains the primary responsibility of the physician with regard to these products. Many of the new cosmeceuticals in development sound very exciting, but the physician’s concern is to help patients choose the best products available today.

Some experts recommend that physicians pick one or two products with which they have experienced good results and advise their patients on how to incorporate them into their daily skin regimen--always reminding patients that even a safe product can evoke redness, cause irritation, or clog pores if used inappropriately.

As technology advances and cosmeceuticals continue to become more sophisticated and more widely used, the medical profession must continue to take an active role in familiarizing themselves with these products and in educating patients about the benefits and risks of cosmeceuticals.

Katherine Martin, MS4, and Dee Anna Glaser, MD, MSMA member since 1997, is the Vice Chair and Professor of Cosmetic and Laser Surgery in the Department of Dermatology at the Saint Louis University School of Medicine.

Contact: ude.uls@94itramk

This Cosmetic Surgery Mini-Theme Series is the final of three, presented in collaboration with the Missouri Dermatological Society, the Missouri Association of Plastic & Reconstructive Surgeons and the Missouri Society of Eye Physicians & Surgeons.

None reported.