The Last Word: Aesthetics and Science

By Professor Marcos Sforza / 12 Oct 2018

Professor Marcos Sforza argues the importance of using scientifically-supported products across the aesthetics specialty.

Decades ago, medical aesthetic treatments were limited to surgical procedures and of course only conducted by surgically-trained practitioners. However, today, the non-surgical field is of great importance for both plastic surgeons and other aesthetic practitioners, including doctors, dentists and nurses, as well as those trained in skin treatments such as chemical peels and energy-based modalities.

Aesthetic treatments encompass an enormous range of procedures, from relatively minor interventions such as chemical peels, injectables and dermal fillers, to major surgery. However, I believe the rapid growth and diversification of the sector is compounding the difficulties of quality control. I am referring to the huge number and various types of aesthetic products now available on the market, from both reputable distributors to online sellers. I believe it is important that today’s practitioners prioritise, and have a comprehensive understanding of, science-backed aesthetic products from peels to fillers. According to research,1 many chemicals in personal care products have not been tested for safety and different ingredients may also accumulate and interact in potentially harmful ways. Chemical exposure has been linked to rising rates in breast cancer, asthma, autism, reproductive system problems, and other health issues.2

Complaints of adverse health events related to cosmetic and personal care products more than doubled from 2015 to 2016, according to a study in JAMA Internal Medicine.3 This study states that unless we modernise and expand the collection of data about aesthetic and cosmetic procedures, industry professionals will be unable to measure or manage cosmetic results. This is because there will not be the necessary information available for professionals to check whether certain reactions to products like anti-wrinkle injections for example, are common or potentially harmful. Without a wide collection of data, we won’t have a clear idea of the necessary safety regulations, which need to be implemented in advance.

Recognising the gold standard

Some of these issues are partly down to the fact that practising in private medicine removes many of the checks and balances found within the National Health Service, which protect patients from experimentation and exploitation. However, I believe all medical and aesthetically trained professionals should be able to balance company profits with an ethical requirement to do what is best, and scientifically proven, for their patients.

According to a recent study, the general gold standard for scientific testing should be randomised, double-blinded and conducted in a controlled environment. There should be human clinical trials against placebo or an approved prescription product, carried out by an unbiased third-party research group, using the final finished formulation.4

Phrases such as ‘clinically proven’, ‘dermatologically tested’, or ‘salon quality’ are just a few terms I find commonly used by companies and their marketing teams to convey the impression their products are evidence-based and, thus, effective.

Industry professionals should prioritise more scientifically-supported research across the aesthetics specialty

Some businesses also choose not to use higher doses of active ingredients in products, as they can cause side effects such as redness and skin irritation, which is not going to help sales. This is considered acceptable, so long as a product does not contain a pharmacologically-active substance or make medical claims, as it then becomes classed as a medicine.5 Therefore, a fine balancing act is created between producing a product that contains enough active ingredient, but not too much, and marketing it to convince customers it works, without catching the attention of stricter regulation.

But if a product is not made to its full effectiveness, ultimately, it’s the loyal patients who are duped into procedures or treatments, which will only achieve minimal results. As well as this, various manufacturers may refer to studies on individual ingredients, but you should not assume the activity of these ingredients will be maintained when these are mixed with multiple others. For example, titanium dioxide (a naturally occurring mineral often used as a pigment or thickener) is considered to be safe when put into a viscous mixture, such as in sun cream or toothpaste. Yet in powder form, such as in mineral makeup powders, it can cause cancer when inhaled, according to the International Agency for Research on Cancer (part of the World Health Organization).6

Even if there is some science behind an ingredient, manufacturers aren’t required to prove the ingredient works in that product’s specific formulation or concentration. It is also important to consider who conducted the studies on aesthetic treatments. Some companies may claim their studies are sponsored by a third party, when they are conducted in their own in-house laboratories. This may reduce the chance of the data being truly objective.

I believe all medical and aesthetically trained professionals should be able to balance company profits with an ethical requirement to do what is best for their patients

The need for trial and error?

The counter-argument here often focuses on the premise aesthetic treatments are ‘innocent until proven guilty’. The skincare landscape, for example, is vast and more people are trying to navigate it. For ingredients that do have evidence behind them, there are often unknowns that remain.

The proposed study parameters stated earlier are also very expensive for companies to produce, which is potentially another reason why a company may not issue them. If they had to, it would be likely only big pharmaceutical companies would be the ones releasing products, thus creating a monopoly, which also wouldn’t be ideal.

Confronted with the countless product choices and ambiguous information about the efficacy of different products, aesthetic professionals should continue to educate themselves and each other about what works. I believe this is only going to happen if there is some degree of experimentation involved. It’s not like shooting in the dark, of course, but there’s never going to be a ‘one-size-fits-all’ offering to suit everyone who comes in for treatments. A study may prove a product to be generally safe, but products cannot be tested on absolutely everyone, so there might still be an individual who reacts negatively to it. People have different skin types and body shapes; some are more irritated by certain ingredients and people heal in different ways too.

Future solutions

I think industry professionals can and should prioritise and promote more scientifically-supported research across the aesthetics specialty and there are several ways they can do this.

Firstly, clinics should encourage their staff to regularly attend scientific meetings, seminars and conferences organised by the relevant industry bodies, associations and reputable providers, so they remain informed on all the latest innovations and issues occurring across the specialty.

More meetings, discussions and correspondence between stakeholders from all groups – professionals and companies – would be beneficial so guidelines focus more on what data supports certain products, which, consequently, could help integrate both surgical and non-surgical interventions. I think these guidelines should put in place a set standard for how many trials have taken place for a product, how many recipients it’s been tested on and whether these fit with the gold standard for product trials. This means professionals will only be using products with the most extensive research behind them.

Of course, this could one day be a legislative framework that manufacturers and distributors must follow, although due to the current non-regulation of the aesthetics specialty this could be a long wait.

In my opinion however, the specialty is starting to move more in this direction. I think this is because more people are talking about the importance of science-backed products in conferences and in clinics, so more research is starting to take place. Potential changes could include regulations that require vigorous tests on certain ingredients, which should be implemented by the relevant bodies such as the Office for Product Safety and Standards; a government body that was created in January 2018 to enhance protection for consumers and the environment.7

This would help practitioners ensure they have the right skills to recognise whether the products they are looking to use are safe, the providers of such products are responsible and the public get accurate information and support if things go wrong with a certain product.

It would also be useful to implement legislation where more products are tested outside their own research and development teams. I am not saying researchers knowingly twist information about the efficacy of treatments, but there is the possibility internal testing can create conflicts of interest, which impacts how research is presented and interpreted.

Conclusion

Only by providing more transparency around product claims, enhancing training and defining set guidelines for both surgical and non-surgical procedures, will science become a bigger priority in aesthetic practices across the country. Not only this, but if new legislation is enforced, it could help regulating bodies learn more about the long-term health effects of aesthetic and cosmetic products.

References
  1. Harvard T.H. Chan. 2014. Harmful, untested chemicals rife in personal care products. <https://www.hsph.harvard.edu/news/features/harmful-chemicals-in-personal-care-products/>
  2. Harvard T.H. Chan. 2014. Harmful, untested chemicals rife in personal care products. <https://www.hsph.harvard.edu/news/features/harmful-chemicals-in-personal-care-products/>
  3. Kwa, Michael, BA, Welty, Leah, Phd, Xu, Shuai, MD, MSc ‘Adverse Events Reported to the US Food and Drug Administrations for Cosmetics and Personal Care Products’, JAMA Intern Med., Volume 177, No. 8, (August 2017) p. 1069 – 1228
  4. Sullivan, Gail M., MD, MPH, Getting Off the “Gold Standard”: Randomized Controlled Trials and Education Research, Journal of Graduate Medical Education, Volume 3, No. 3, (September 2011) p. 285-289
  5. Chemistry World. 2012. Here comes the science bit. <https://www.chemistryworld.com/feature/the-science-of-skincare/5494.article.>
  6. Scientific American. 2009. Saving Face: How Safe Are Cosmetics and Body Care Products? <https://www.scientificamerican.com/article/how-safe-are-cosmetics/.>
  7. Office for Product Safety and Standards (UK: GOV.UK, 2018) < https://www.gov.uk/government/organisations/office-for-product-safety-and-standards/about>

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