Topical: Male Skincare

By Dr Rachael Eckel / 01 Nov 2014

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Dr Rachael Eckel looks at the nuances of treating male skin with cosmeceuticals

The male population seeking cosmetic improvement is swiftly growing. From 2000 to 2005, there was an overwhelming 44% increase in minimally invasive cosmetic procedures among males, according to the American Society of Plastic Surgeons.¹ Similar to women, men hope to display an attractive, vibrant, and healthy outward appearance lending to improved self-confidence.² There are, however, pivotal differences in expectations, motivations and decision-making. Men want a minimalistic approach and are intolerant of delayed downtime.² Their decisions are made rapidly and centred less upon youthfulness and more upon increasing attractiveness and marketability in the workplace.^1,2 It is important for clinicians to identify the discrete nuances when caring for male patients, which are both anatomical and psychological. Topical agents that are recommended should respect these biological differences, remaining simple yet effective. With a male skincare market worth £25 million in 2012 and growing 4% year on year, this is a demographic that necessitates attention (Table 1).³

	2011	2012	%YoY
Total skincare	£447M	£469M	+4.7%
Women skincare	£423M	£443M	+4.7%
Men skincare	£24M	£25M	+4.4%

Table 1: UK prestige skincare category value growth³

Anatomical Considerations

Cutaneous gender differences are extensive, primarily mediated by sex hormones.⁴ In men, the surge in androgens affects many functions of human skin and its appendages. The impact of testosterone on the sebaceous glands means that male skin is markedly oilier.⁵ Excess sebum clogs pores leading to blackheads and patulous follicles. Such textural irregularities are particularly prominent over the facial convexities where oil glands cluster. Seborrhoeic eczema is a common consequence classically observed peri-nasally and over the eyebrows.⁶ Male skin, both epidermis and dermis, is typically 20-30% thicker than that of females.⁴ This remains true for all ages with extent varying upon anatomical region.⁴ Similarly, vascularity and skeletal muscle mass are more pronounced. The comparative lack of subcutaneous adipose tissue, irrespective of age, gives a more defined, chiselled appearance to the male facial structure.⁴Hormonal influences also affect the distribution of male hair. When present, it offers continuous photoprotection and maintains youthfulness. Conversely, when hair is absent, especially over locations such as the scalp and ears, the risk of developing skin cancer increases considerably.⁷ This is further compounded by these regions being difficult to self-examine, encouraging late presentations of advanced disease. The habits associated with male grooming (and specifically shaving) can lead to disease such as pseudofolliculitis barbae, which reaches an alarming 85% prevalence amongst males of African descent.⁸ Excess facial hair also permits an increased surface area for bacterial colonization. This may explain why acne presents more severely amongst males. A 2009 study published in Perception identified a noteworthy difference in skin contrast between genders.⁹ Regardless of race, female faces have lighter skin when compared to males; hence ‘the fairer sex’. The colour intensity of female eyes and lips however, match those of males, providing a more striking contrast to their lighter surrounding skin. Such juxtaposition influences our perception of the facial gender. This is the reasoning behind females applying makeup; to exaggerate sexually dimorphic attributes, making the face appear womanlier.⁹ Anatomical differences between sexes also result in ageing disparities. Men show fewer but deeper rhytids when they lose subcutaneous adipose with age.4 This is because of their thicker skin and prominent facial musculature. Conversely, females have more numerous and superficial expression lines, especially in the perioral region.⁴

Psychological Factors

There is a relative lack of male-specific studies in aesthetics. But clinical practice and market research strongly suggest that a gender specific stratagem is imperative. The male approach to dermatology and aesthetics tends to be reactive rather than proactive. Men are less concerned with anti-ageing, and present to clinicians with a specific problem, for example, rosacea.Dermatoses tend to be advanced and require numerous ancillary procedures to effectively remedy because of the late presentation. Behaviourally, I find men to be more passive dermatologic patients; they ask fewer questions and are less likely to highlight their concerns. Furthermore, their knowledge about skincare is often misguided and their daily topical regime reflects this disservice. This is particularly compelling with regards to their lack of photoprotection, which lends to men having remarkably higher rates of all types of skin cancer compared with women.⁷

Figure 1: Nodulocystic acne. Patient shown before and after treatment for eighteen weeks using cleanser (Oilacleanse), mechanical scrub (Exfoliating Polish), sebostatic pads (Cebatrol), antioxidant protection / DNA repair / barrier restoration (Daily Power Defence), sunscreen (Oclipse M SPF 30), alpha-hydroxy acid exfoliant (Glycogent), vitamin A (retinoid acid 0.1% and Melamix)

In fact, men over 50 are more than twice as likely to develop and die from skin cancer.⁷ The poignant behavioral reasons underlying this are manifold and detailed in Table 2. Although there exists a knowledge gap for the importance of UV protection amongst men, a recent Australian study showed that when men receive information about protecting their skin they respond positively, and adopt a photoprotective regime.^10,11 Men can therefore be mobilised to take an active role in their skin health through education about sunscreen, early detection and prompt treatment. With this in mind, the male patient’s general consultation needs to be thorough and directive to engage him. It should be centred upon attentiveness, asking open questions and education. Explanations must be simple yet detailed and video references provided where available, as these have been proven to be more effective than brochures within this patient cohort.¹² When advocating topicals, consideration should be given to numerics and marketing. On average, males use half as many daily products when compared to females.¹³ Typically their skincare regime will fit into one of the following groups, they (1) use soap and water primarily; (2) cherry pick products from their partner; or (3) purchase male specific topicals. Regarding the latter, when manufacturers create a gender-focused product they employ stereotypical ideas of masculinity to target shoppers.
Product imagery tends toward science and tool-like shapes rather than flowers and fruit showcased on women’s packages.¹³ Fragrance is another area of divergence, as is presented ingredients. Women are more allured by botanical extracts (e.g. Indian gooseberry, liquorice root) and holistic skincare components compared with men. In reality, his and her product lines are indistinguishable.¹³ They contain almost identical ingredients rebranded to suit the gender and consumer desires rather than skincare needs. While there exists a notable difference in male psychology and marketing strategy, it is important to remember that clinicians should base their product recommendations on science and efficacy. Of note, approximately 80% of all cosmeceuticals currently available on the market use ingredients that have not shown any clinically proven benefit.⁵
A skincare line that combines active ingredients based on novel science with targeted delivery systems is a preferred choice. Fragrance should be limited as this is irritating, but where present it should be clean and unisex.

Table 2

Men prefer a baseball cap style for protection yet this only protect the forehead and frontal face. The neck, ears, and sides, the most high risk anatomically for male skin cancer, remain exposed.
Men spend 10 more hours a week in the sun compared to women due to outdoor work and sports.
A recent survey found that 1 in 2 men had not applied sunscreen in the past 12 months and only 32% considered themselves knowledgeable about how to properly use it. Furthermore, nearly two-thirds of these men believed women needed sunscreen more because female skin has greater UV sensitivity.
Men are three times more likely to avoid physicians when there is a persisting minor medical symptom. Men present with larger, thicker, more invasive melanomas and this is likely the reasoning. Furthermore, they neglect routine screenings for skin cancer, even if sent reminders and offered free of charge
Education and advertisements for sunscreen appear primarily in publications aimed at women. In a 5 year review of 24 different magazines, 77% of sunscreen ads were in female magazines and none mentioned correct application method.
53% of women protect themselves at least sometimes with sunscreen, compared to only 36% of men. They also apply too little volume and reapplication is seldom.

Table 2: Behavioral considerations underlying male sunscreen usage^6,9,10

Skincare in Execution

When men describe the skin they hope to achieve, they use adjectives such as clean, fresh, vibrant, clear and smooth. On a cellular level this translates into homogenous melanin distribution, effective keratinocyte turnover, ample collagen and elastin output, absence of active disease, natural hydration and intact barrier function. This, by definition, is healthy skin where all cutaneous cells are functioning optimally.⁵ The favoured male approach to achieving such holistic outcome is minimalistic.
A regime with few steps and maximal gains will yield the greatest compliance. Remembering that the male client is unlikely to be using an elaborate protocol already, initial topicals selected should focus on providing skincare fundamentals. This includes the removal of sebum and debris, enhancing keratinocyte exfoliation, repairing the barrier function, controlling inflammation and protecting against UV damage. These may be easily achieved by following five practical steps.

Basic Skin Hygiene (Steps 1-3)

The following three daily steps are indispensible. Together they form the pillars for maintaining pilosebacious health through oil reduction, enhanced cellular exfoliation, and inflammation suppression. The skin’s delicate lipid bilayer that contributes to barrier function must be simultaneously respected and restored by selecting balanced formulations.

The face should be washed twice daily for 40-60 seconds with a cleanser that solubilizes and facilitates the removal of sebum and skin soils. Salicylic acid, a beta-hydroxy acid, is particularly effective at digesting such irritants. Tepid or cold water should only be used, as heat is irritating. Washes that contain micro-beads are particularly appealing because they assist in shedding dead cells.
An exfoliating mineral scrub used once daily for 40-60 seconds will gently lift dead keratinocytes, and promote cellular turnover. Such mechanical exfoliation will simultaneously clean pores from pollutants and improve irregular texture. Ingredient edges should be finely polished so as not to cause microtears and irritation.
To remove any residual impurities and minimise inflammation throughout the day, oil control pads containing a blend of witch hazel and chemical exfoliants (e.g. alpha- hydroxy acids, mandelic acid) should be employed twice daily. These will reduce irritation while maintaining a small pore size and smooth texture through enhanced keratinocyte exfoliation. An emollient complex can be further added to soothe skin and restore vital lipids lost through cleansing and shaving.

Antioxidant Protection, DNA Repair, and Barrier Restoration (Step 4)

A comprehensive topical agent containing antioxidants, DNA repair enzymes and barrier replenishing agents should be applied to the skin daily. The reasoning for this is as follows:

A diverse bouquet of antioxidants (e.g. vitamins A, B, C, E, Coenzyme-Q10, plant extracts and stem cells) will provide a multimodal benefit platform to both repair and protect against oxidative stress. Topical antioxidants are also particularly effective at quelling UV and pollution-generated free radicals. Once daily application will yield 24 hour-long protection, and a cumulative benefit occurs when used regularly.
Sun exposure damages DNA, leading to skin cancer and wrinkling. DNA repair enzymes can be applied to skin to mend such ruin. These scan mitochondrial and nuclear DNA for injury and subsequently fix the distorted portion. One sub-type, roxisomes, speeds up DNA repair from 24 hours down to two. These enzymes also reduce UV-generated cell death, cytokines, and matrix metalloproteinases. Together with antioxidants, they increase the skin’s innate resistance to UV light, and the subsequent inflammation induced.
The specialised barrier function of the epidermis is delicate; easily disrupted and lost. UV radiation and pollution are common culprits that compromise the skin’s integrity leading to sensitivity and dryness. To replenish and preserve the skin’s barrier, a diverse group of physiologically relevant lipid fractions and humectants (e.g. ceremides) should be strategically applied daily.

UV Protection (Step 5)

Daily application of a broad-spectrum sunscreen with an SPF value of 30 or greater is advocated. A comprehensive formulation suited to the skin type and colour should be selected. Physical blocks (e.g. titanium dioxide, zinc oxide) are superior to their chemical counterparts because they are less irritating and last twice as long. Fractionated melanin is a novel ingredient to look for in sunscreen, providing 10 hours of continued protection against High Energy Visible (HEV) rays, which can be more injurious and penetrate deeper than UVA.

Optional Shaving Balm

The most popular product purchased by men in the UK is a shaving lubricant.³ If facial grooming involves shaving, this should follow the exfoliating scrub step. It is ideal for the chosen product to be free from fragrance and colour to minimise irritation. The latter will also benefit patients with ‘designer beards’, permitting more precise grooming. Formulations replete with antioxidants (e.g. vitamin E) and anti-irritants (e.g. niacinamide) are particularly appealing to concurrently soothe the skin. The incorporation of physiologically relevant lipids (e.g. glycerin, mannitol) will preserve the delicate barrier function and mitigate the mechanical damage caused by razors.

Incremental Additions

Once the male has integrated these five basic steps successfully into their habitual daily practice, other topical agents can be supplemented to augment the regime efficacy. These should be introduced incrementally (e.g. every six weeks, one skin cell cycle) to capitalise on compliance. The following ingredients represent the most appropriate additions to consider:

Alpha-hydroxy acids (e.g. lactic acid, glycolic acid) will increase cellular turnover to curtail trapped sebum and soften texture. Pore minimisation that occurs will also have a direct impact on suppressing the superficial output by the sebaceous gland.
Benzoyl peroxide is a useful supplement for patients with particularly oily skin. It diminishes seborrhea and acts as an antimicrobial agent. Micronized technology should be preferentially elected, as it does not induce irritation.¹³
Vitamin A provides extensive improvements to the epidermis and dermis. These include softer skin, sebum reduction, smoother texture, smaller pores, improved hydration, a decrease in lesion counts, evening of pigmentation, reduced sensitivity, and potent anti-ageing benefit. When disease is present retinoic acid should be used up to 18 weeks, and the retinol moiety long term for maintenance purposes.^4,13
Although conditions of pigmentation (e.g. melasma) are less frequent amongst males, when present they must be addressed. Hydroquinone can be used in a brief, pulsed manner to control disease and a non-hydroquinone approach adopted for maintenance. Unnecessary skin lightening tends to be avoided in males as this feminises the face.8

Interestingly, geographic location has an impact on product selection and grooming attitude. Within the UK, men in London, the North West, Yorkshire/North East/Borders and Ulster display a more sophisticated outlook to skincare.³ In particular, London males are early adopters, and are more likely to purchase luxury items.³ With this in mind, the clinician may choose to adapt their recommendations to suit the cultural climate. Likewise, when cutaneous disease is present causing disfigurement and distress, the incremental approach may be dismissed. In such circumstances, male patients are keen to rapidly inactivate the condition and dedicate more time to skincare.
More lengthily regimes may instead be appropriate at the therapeutic onset, and reduced for maintenance.

Conclusion

The male market seeking cosmetic improvement is growing sizably and with this follows increased questions about skincare. In order to successfully treat this cohort, clinicians must remain aware of the existing anatomical and psychological nuances. Consultations should focus on education and this is especially critical in relation to the male skin cancer epidemic. To drive compliance, initial regimes must be minimalistic, focusing on fundamental skin health principles. These can be further supplemented incrementally to augment the programme efficacy whilst nurturing a habit. Topical agents selected should contain active ingredients that are science based with proven results. A holistic approach is advocated to achieve maximal skin health by restoring, protecting, and strengthening all cellular functions.

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