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Skin Care Products: What do they promise, what do they deliver

Article  in  Journal of Tissue Viability · March 2016

DOI: 10.1016/j.jtv.2016.03.006

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Skin care products: What do they promise,

what do they deliver
Christian Surber a,b,*, Jan Kottner c

a
Department of Dermatology, University Hospital Basel, Switzerland
b
Department of Dermatology, University Hospital Zürich, Switzerland
c
Clinical Research Center for Hair and Skin Science, Department of Dermatology and
Allergy, Charité-Universitätsmedizin Berlin, Germany

KEYWORDS Abstract The industry offers a vast armamentarium of skin care products to
Skin care; clean, soothe, restore, reinforce, protect and to treat our skin and hence to keep
Vehicle; it in “good condition”. Skin care products are readily available and their promotions
Topical administration; with fanciful claims are omnipresent. The promotions are based on effects, evoked
Nursing; by actives that are delivered through vehicles that rely on specific technologies.
Cosmetics/administra- Due to the fact, that these products are in direct contact to the target tissue, their
tion & dosage; vehicle and ingredients are able to profoundly modulate the characteristics of the
Cosmetics skin and some of its functions. This makes products for the skin absolute unique and
versatile delivery systems. This paper discusses the concept of skin care and skin
protection, the choice of skin care products, their vehicles, their functionality
and their regulatory status.
ª 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction soothe, restore, reinforce, protect and to treat our

skin and hence to keep it in “good condition” [1,2].
Our skin reflects our origin, lifestyle, age and state Skin care products are readily available in daily life
of health. Skin color, tone and evenness, pigmen- and they play a major role in health and nursing
tation, as well as skin surface characteristics are care. The promotion of skin care products
signs of our skin’s health. The cosmetic and phar- including their claims are often based on an effect
maceutical industry offers a vast armamentarium (e.g., moisturizing, antioxidant), evoked by an
of skin care products and procedures to clean, active (e.g., urea, tocopherol) that is delivered
through a vehicle (e.g., lotion) that relies on a
specific technology (e.g., nanotechnology). In
* Corresponding author. Department of Dermatology, addition “without” claims (e.g., without para-
Gloriastrasse 31, CH-8091 Zürich, Switzerland.
bens) often accompany nowadays promotions.
E-mail address: [email protected] (C. Surber).

http://dx.doi.org/10.1016/j.jtv.2016.03.006
0965-206X/ª 2016 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
2 C. Surber, J. Kottner

Some of the effects, actives, vehicles and tech- need of care and protection also change. In
nologies have become well-known. The pharma- younger years environmental noxes (e.g., UV ra-
cologic, immunologic or metabolic effect of diation) are of primary importance whereas in
medicinal products e e.g., to treat hand eczema advanced years age-related noxes (e.g., prolonged
or acne e is assigned to an active pharmaceutical exposure to various sources of moisture, including
ingredient (API), e.g., corticosteroids, retinoids. It urine or feces, perspiration, wound exudate, and
is common knowledge that the vehicle housing the their contents) become more important. Subse-
API plays a crucial role in delivering the API to its quently the skin areas in need of care and pro-
target site. Unfortunately many assign the vehicle tection also change e initially skin areas (e.g.,
effect to its entirety (e.g., ointment, cream, gel) face, arms, legs) exposed to the the external
and not to the sum of ingredients forming the environment and later enclosed skin areas (e.g.,
vehicle that remains on the skin after application skin folds, perianal, perigenital skin, groin, feet)
(see section Metamorphosis of the Vehicle). Skin become the vulnerable zones (hot spots) [5,6].
care products rarely house APIs but rather so- Ageing per se changes the skin structure and
called actives or cosmetic actives. These prod- function across the life course increasing its sus-
ucts are classified in some specific cases as medical ceptibility to numerous clinical relevant skin
devices but in a majority as cosmetics. In all these problems (e.g. xerosis cutis) [7]. Skin diseases
cases, too, the vehicle plays a crucial role in (e.g., bacterial/fungal infections), accumulating
unleashing an effect on the skin. This is due to the effects of systemic diseases (e.g., diabetes melli-
fact, that the target tissue is directly treated and tus, renal insufficiency) or pharmacotherapies
the vehicle and their ingredients are able to pro- (e.g., cancer therapies) also necessitate special
foundly modulate the characteristics of the skin skin care.
and some of its functions. This makes products for
the skin absolute unique and versatile pharma-
ceutical and cosmetic delivery systems. 3. Skin care procedures and skin care
Against this background we discuss the concept products
of skin care and skin protection, the choice of skin
care products and their vehicles, their function- The information on skin care procedures is plen-
ality and their regulatory status. tiful but little scientifically documented and the
number of products available for cleansing,
soothing, restoring, reinforcing and protecting is of
2. Concept of skin care and skin an almost infinite variety. Nonetheless their func-
protection tionalities may be described as

The concept of skin care is not well defined. It is a  Removal of dirt, sebum, microorganisms,
kind of umbrella term covering cleansing, exfoliated corneocytes and other non-wanted
perfuming, changing appearance, changing body substances from the skin
odor, protecting and keeping the skin in “good  Reduction of unpleasant skin symptoms (e.g.,
condition”. In the last decades our perception of pruritus, burning, odor)
skin care has broadened and soothing of skin  Restoration of (subclinically) damaged skin
symptoms/conditions, and improvement and (e.g., dry and inflamed skin)
restoration of the skin’s barrier function and  Reinforcement of undamaged but vulnerable
integrity have been added. Today, modern skin skin (e.g., skin surface pH balance, germ
care includes cleansing, soothing, restoring, rein- reduction)
forcing and protecting. With increasing age the  Protection of damaged, undamaged and
emphasis on skin care is changing [3,4]. The vulnerable skin from various noxes
importance of soothing, restoring, reinforcing in-  Providing a pleasant skin feel (well-being).
creases and cleansing should be executed with
particular care. The character of skin care shifts The functionality of the skin care products
from more cosmetic objectives e smooth, healthy ranges from mono-functional, e.g., protecting
looking skin e to more therapeutic and preventive barrier creams to poly-functional, e.g., soothing
objectives e soothing, restoring, reinforcing and and restoring cleansers. They unfold their func-
protecting stressed skin. Even though skin care and tionality as leave-on products (e.g., moisturizing
skin protection plays an important role throughout or skin barrier products), or as rinse-off products
lifetime the noxes and the skin areas in primary (e.g., cleansers). Skin care procedures e washing/

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
Skin care products 3

drying and the application of leave-on products e ingredients, are mixed and stabilized an emulsion
should be as benign as possible. The unduly results. In pharmaceutics and cosmetics the
removal of natural skin component (e.g., lipids), emulsion is termed as a cream or a lotion. Creams
prolonged exposure to water (e.g., long-term im- are semisolid whereas lotions are more liquid. The
mersion in full-baths), a (repeated) disruption of difference between these two forms is primarily
the physiological skin surface pH, and excessive viscosity. Depending on the ingredients (emulsi-
and/or prolonged occlusion of the skin should be fiers) chosen to stabilize the emulsions, the
avoided. emulsion may become an oil in water (o/w) or a
Skin care delivered to improve, e.g., the water in oil (w/o) emulsion (Fig. 1).
outcome of an eczema therapy or to reduce, e.g.,
the adverse effects of a cancer therapy are often 4.2. The metamorphosis of the vehicle: the
termed as adjuvant skin care. Nonetheless, adju- primary and secondary vehicle
vant or the above described classic preventive skin
care pursues the similar goals. In the case of an oil in water (o/w) emulsion the
lipophilic (inner) phase is dispersed in the hydro-
philic (outer) phase. In the case of a water in oil
4. The choice of vehicle (w/o) emulsion the hydrophilic (inner) phase is
dispersed in the lipophilic (outer) phase. It is easy
There is an overwhelming range of skin care to imagine that the sensory character of the
products on the market with a multitude of emulsion on the skin may be very different. Due to
promises and application recommendations. The evaporation of water the oil in water emulsion may
latter often includes recommendations regarding convey the immediate impression of “cooling”. A
the choice of vehicle. However, these recommen- considerable number of ingredients that are used
dations are unfortunately often founded on faulty in many current topical formulations are volatile,
science. One reason is the absence of a clear and e.g., water, alcohol and even propylenglycol. Once
persuasive terminology for vehicles. Current rec- applied to the skin, the evaporation of volatile
ommendations rarely differentiate between ingredients may dramatically change the character
vehicle effects (moisturizers, emollients, humec- of the vehicle once applied to the skin. This phe-
tants, etc.) and vehicle formats (ointments, nomenon is termed as metamorphosis of the
creams/lotions, gels etc.), e.g., “a moisturizer is a vehicle (Fig. 2) [9].
cream for application on face and body”. From This phenomenon becomes often recognizable
many recommendations suspicion may arise that as the visual aspect of the skin surface is changing.
the essence of the vehicle is not fully understood, It gives the false impression to both consumers and
e.g., “. unlike lotions, which do not maintain
moisture in the skin, cream moisturizers donate
moisture and aid in retention of moisture on the
skin surface .” [8]. The terms “moisturizer” and
“emollient” are often used interchangeably,
despite the fact that they describe different
mechanisms. Conceptually a moisturizer adds
moisture to the tissue whereas an emollient
softens a tissue and makes it flexible. Both, mois-
turizers and emollients may, or may not have
softening and moisturizing effects.

4.1. The concept of vehicles

Without going into physicochemical details one Fig. 1 Depending on the ingredients (emulsifier) cho-
may define a vehicle as a mixture of a series of sen to stabilize the emulsions, the emulsion may become
ingredients that forms a three dimensionla matrix an oil in water (o/w) or a water in oil (w/o) emulsion.
Semisolid emulsions are termed as creams whereas more
or format, e.g., ointment or cream, etc. The
liquid emulsions are termed as lotions. The difference
physicochemical character of the ingredients
between these two formats is primarily viscosity. It is
chosen and the manufacturing process determine also easy to imagine that the sensory character of the o/
the final format of the vehicle e the three w and the w/o emulsions on the skin may be very
dimensional matrix. E.g., when two immiscible different. Due to evaporation of water the o/w emulsion
liquid phases, each may contain several may convey the immediate impression of “cooling”.

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
4 C. Surber, J. Kottner

1 seconds 15 seconds 30 seconds

after application after application after application

Fig. 2 In clinical situations, most topical vehicles (structural matrix and ingredients) undergo considerable changes
after they are removed from the primary container and are applied onto the skin. The fast breaking foam spray is a
distinctive example for the metamorphosis of the vehicle. This phenomenon tempts both consumers and professionals
to believe that the product is well absorbed, even though only volatile ingredients are evaporating. Relevant pene-
tration into and permeation through skin (absorption) of any ingredient may demand more time than for the meta-
morphosis of the vehicle [9].

professionals that the product is well absorbed, appropriate cleansing product/procedure has to
even though only volatile ingredients are evapo- be chosen. Viscosity is another important product
rating. Absorption into or through the skin of any feature that should be considered. Low viscosity
ingredients e active or inert e demands much products are preferably used on larger skin areas,
more time. whereas high viscosity products are used on
As a consequence one may differentiate be- smaller areas. As a consequence for the future one
tween two types of vehicles e the primary vehicle may expand previous criteria of vehicle choice
in the tube, bottle or jar and the secondary vehicle (ointment, cream/lotion, gel, paste) and also use
that forms after application on the skin. The latter polarity (hydrophilic vs. lipophilic) and viscosity
has lost all or significant amounts of its volatile (low vs. high). Hydrophilic vehicles are more suit-
ingredients. In addition the original three- able for moist and lipophilic vehicle are more
dimensional matrix may have completely suitable for dry skin conditions. Low viscosity ve-
changed. The primary vehicle is responsible for the hicles are more suitable for larger whereas high
application sensation whereas the secondary viscosity vehicles are more suitable for smaller skin
vehicle is responsible of the subsequent skin feel areas (Fig. 3) [9].
and long-term effect. For daily practice, healthcare professionals,
patients and consumers may put more emphasis on
4.3. The polarity (hydrophilicity vs. lip- polarity and viscosity of the vehicle rather than
ophilicity) and viscosity of vehicles the vehicle format. As these features are rarely
mentioned on the product labeling or in the
The properties of ingredients e hydrophilic (solu- accompanying information only own previous
bility in water) or lipophilic (solubility in oil) e experience or recommendations from third parties
chosen to formulate the vehicle, determine its may help to choose the adequate product of
final character. This means e theoretically and preference. Another option is to rely on the func-
practically e that for most of the vehicles (e.g., tionalities claimed on the product.
ointments, creams/lotions, gels and pastes) a hy-
drophilic and a lipophilic form exist, e.g., hydro-
vs. lipolotion or hydrogel vs. oleogel. From a 5. Product functionality
practical point of view, it is important to note,
that lipophilic formulations are often less effec- 5.1. Cleansing products
tively removed from the skin than hydrophilic
formulations. In the case of stressed skin topical Skin cleansing includes washing, showering and
formulation must be easily removable and an bathing. It removes dirt, sebum, microorganisms

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
Skin care products 5

wet/moist Skin / Dermatosis dry

high small
5 6
4 7

Area to be treated
Viscosity 3 8

2 9

1 10
low large

hydrophil Polarity lipophil

Fig. 3 From a theoretically and practical point of view polarity (hydrophilic vs. lipophilic) (x-axis bottom) and
viscosity (low vs. high) (y-axis left) are relevant vehicle features to consider when choosing a product. Hydrophilic
vehicles are more suitable for wet/moist and lipophilic vehicles are more suitable for dry skin conditions (x-axis top).
Low viscosity vehicles are more suitable for larger whereas high viscosity vehicles are more suitable for smaller skin
areas (y-axis right). Typical vehicles are: (1) aqueous solution; (2) o/w- or hydrolotion; (3) o/w-cream; (4)
hydrogel, hydrophilic ointment; (5) cross-linked hyaluronic acid gel (cubed water); (6) lip stick; (7) lipogel,
lipophilic ointment; (8) w/o-cream; (9) w/o- or lipolotion; (10) oil [10].

and exfoliated stratum corneum cells from the also be questioned because significant amounts
skin. Cleansers are products that are used as such, are lost during cleansing. Acidic cleansers with
added to the washing water or are part of wipes to “mild” surfactants (non-ionic/silicone-based sur-
remove debris from the skin in an emulsified form. factants) e minimal disturbance/disruption and
The key cleansing ingredients are the “surfac- yet high rinsibility e are generally recommended
tants” e a term derived from the words “surface” to cleanse vulnerable skin [2,6]. There may be
and “active” e that lower the surface tension on situations in clinical practice, in which the expo-
the skin and hence remove the debris. “Syndet” is sure to water and cleansers must be restricted to a
another portmanteau word created by combining minimum, e.g., severe xerosis cutis [16].
the words “synthetic” and “detergent”. Soaps
were the first surfactants people used for 5.2. Soothing, restoring, reinforcing
cleansing. They are made by reacting fatty acids products
with a base (e.g., sodium hydroxide) e a process
that is called saponification. All the terms are Even though there are linguistic differences be-
often used as linguistic synonyms even though the tween the terms soothing, restoring, and rein-
physicochemical difference between the classic forcing, it is difficult to subcategorize products
soap and syndets/detergents is distinctive. Tradi- accordingly. The soothing character of a product
tional soaps have a pH of 9 to 10 whereas syndets/ can rarely be awarded to a single substance in the
detergents show a pH of 5 to 6 [11]. The latter pH product. Products restoring the skin (e.g., mois-
is preferable for the skin and it was shown that the turization) will most likely soothe the skin (e.g.,
artificial reduction of the skin surface pH promotes pruritus). Reinforcing products will create or sup-
the skin integrity in aged and compromised skin port natural and healthy skin conditions (e.g.,
e.g. [12]. Depending on the emulsifying capability acidic skin pH, limit bacterial/fungal growth).
of the surfactants, they may disturb or disrupt the
skin barrier and hence aggravate unfavorable skin 5.3. Protecting products
conditions [13,14]. Cleansers may contain antimi-
crobials (e.g., benzalkonium chloride or iodine) or “Barrier cream” is the colloquial term for topical
humectants (e.g., glycerin) or occlusives (e.g., products that are placed as physical barriers be-
paraffin) to compensate cleansing-induced dam- tween the skin and contaminants that may harm the
age. Because cleansers are rinse-off products the skin. “Barrier creams” may also be intended as
effectiveness of antimicrobial additives has been products that may restore damaged skin. In this
questioned [15]. The effect of other additives may sense, any moisturizing or emollient product can

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
6 C. Surber, J. Kottner

also be considered as potential skin barrier im- allantoin, ascorbyl palmitate or ubiquinone
provers [17]. Unfortunately, the terms are used (CoQ10) etc. for generic actives and Soothex
vaguely e both in guidelines and scientific papers. (soothing action for sensitive or over-reactive skin
Furthermore “cream” is just one possible vehicle types) or Yogurtene Balance (probiotic efficacy;
format of such products e other forms such as promotes beneficial bacteria) etc. for branded
ointments, pastes, sprays or foams also exist. To actives. Unfortunately the claim substantiation is
avoid linguistic misunderstandings one may differ- often poor and do not comply with current scien-
entiate between “barrier products” and “barrier tific standards.
repair products” (see also restoring products). The
first is defined as a product that provides primarily a
barrier against noxious agents, the latter is defined 7. Regulatory issues
as a product with the clear intention to restore and
reinforce the skin. However, barrier products obvi- Skin care products can theoretically be assigned to
ously do not work only based on a physical shielding three different regulatory classes e medicinal
of the skin; they may also alter the biochemistry of products, medical device and cosmetics. For me-
the potential irritant [18]. Barrier products cannot dicinal products and medical devices a health
simultaneously provide a barrier against all noxious promise is allowed whereas for cosmetics a health
agents. It is generally believed that more lipophilic promise is prohibited. The health promise refers to
formulations are effective against hydrophilic so- the preventive and/or therapeutic purpose of the
lutions of irritants, and hydrophilic formulations are medicinal product or the medical device. They
more effective against lipophilic materials. Even achieve their principal intended action in or on the
though studies have shown effects of barrier prod- human body by pharmacological, immunological or
ucts in age-associated skin conditions (prevention of metabolic means (medicinal products) or by non-
superficial pressure ulcers and incontinence- pharmacological, non-immunological or non-
associated dermatitis) their general benefits are metabolic means (medical device), respectively.
still debated [2]. Functionality is an adequate mean Cosmetics are meant to clean, to perfume, to
to describe a skin care product and alleviate the change appearance, to correct body odor, to pro-
product choice. However, the industry is prone to tect and to keep in good condition [1]. Currently
exaggerated embellishments of the product func- the majority of skin care products are cosmetics.
tionality and reliable choices are often difficult. For medicinal products and medical devices the
indication are clearly labeled, e.g., xerosis cutis or
pruritus. In cosmetic products claims often
6. The vehicle and the actives describe their functionalities and may be as simple
as “soothe signs of dry skin” but may also be more
A vehicle is something that carries, delivers, fanciful like “Multi-Ingredient Anti-Aging Moistur-
transports etc. A vehicle for topical application izer Designed to Improve the Appearance of Facial
may carry, transport or deliver APIs or cosmetic Skin” [19]. It is important to note, that while the
actives. While often expected, the effect of most boundaries of the three regulatory classes seem
skin care products cannot be assigned to one single well defined, there are many examples to
“active” ingredient. The following example may demonstrate that these boundaries are not as well
illustrate this fact. A skin care lotion may contain defined as one may assume. For instance identical
glycerin, dimethicon and/or paraffin. They are products are marketed as cosmetics or medicinal
concurrently integral part of the vehicle and active products in different European countries. Occa-
ingredient. Glycerin (hydrophilic ingredient) sionally, you will find that regulatory bodies will
termed as humectant attracts water from the question promotional claims and require commer-
environment and from within the skin once pene- cial suppliers to provide additional substantiation
trated into the stratum corneum. Dimethicone or change the products’ claim. To increase pro-
and/or paraffin (lipophilic ingredients) are termed fessional credibility and reputation some com-
as occlusives keep the moist within the skin by mercial organizations promote their products as
decreasing transepidermal water loss of the skin cosmeceuticals and more recently started to
through occlusion. These ingredients formulated conduct clinical trials with their cosmetic products
into emulsions (moisturizing creams or lotions) [20,21]. It is obvious that the label “clinical
serve concurrently as vehicle ingredients and as proven” has a promoting and valorizing effect.
actives. However, it does not change the regulatory status
The range of generic and branded actives that is of the product and the permitted claims. A well-
offered worldwide is overwhelming. Examples are known example ingredient is Aloe vera

Please cite this article in press as: Surber C, Kottner J, Skin care products: What do they promise, what do they deliver, Journal of
Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
Skin care products 7

incorporated in many topical formulations. The the fact that no health claims are allowed for skin
authors of a recent Cochrane Review on the effect care products classified as cosmetics this product
of Aloe vera topical agents or Aloe vera dressings category is successfully promoted in the skin care
as treatments for acute and chronic wounds came business.
to the conclusion that there is currently insuffi-
cient clinical trial evidence available [22]. This
was primarily due to the lack of high quality trials Conflicts of interest
with adequate methodology. Currently, this judg-
ment also applies to many of the “active” cosmetic There are no conflicts of interest.
ingredients and their supposed effects.
This regulatory situation is unknown to most of
the consumers and healthcare professionals. They References
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care products are classified as cosmetics. Despite

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Tissue Viability (2016), http://dx.doi.org/10.1016/j.jtv.2016.03.006
 8 C. Surber, J. Kottner

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