Retinol is a form of vitamin A. This gets converted into the active form called retinoic acid. This ingredient has many powerful actions in the skin including –

• Stimulation of collagen, elastin & hyaluronic acid. This accounts for the anti wrinkle effects of retinoids.
• Reduction of pigmentation via inhibition of melanin production, as retinoids suppress the enzyme called tyrosinase. This can improve melasma & sun spots.
• Retinoids compacts the upper most layer of skin called the stratum corneum, accelerates turnover of skin cells & thickens the epidermis. This results in better light transmission, more luminous skin & less wrinkles.
• Vitamin A also reduces oil production, and hence why it is the mainstay of treating acne, enlarged pores & oily skin.
• Retinol also increases blood vessels, a term called angiogenesis. This results in glowing dewy skin.

A more powerful form of vitamin A is called retinaldehyde.

This requires only one conversion step before becoming retinoic acid. Retinol Esters are weaker, and hence why they are used in patients with sensitive skin.

Retinoid like molecules include granactive retinoid or hydroxypinacolone retinoate, & bakuchiol. These molecules are less irritant than traditional retinol.

The major drawback of retinol & retinoids is their potential to cause skin irritation. This is proportional to their strength (formulation percentage) but also depends on the formulation. As a guide, most experts will advocate a lower strength retinol to start with, thereby increasing the concentration over a period of time- usually 3- 6 months.

Understanding what your skin can tolerate is the first step in good skin care. Prescription retinoids such as tretinoin, retinoic acid, adapalene &  tazarotene will cause skin irritation. It is a matter of application amount & frequency.

A much more sensible approach is to start off with over-the-counter retinoids including retinol, retinyl esters, & retinaldehyde. These compounds require conversion to pharmacologically active retinoic acid. These conversion steps slow down the process to yield bioavailable retinoic acid, in turn markedly reducing side effects.

Start off with good formulations of say, 0.5 % retinol, increasing to 1.0% over 3-6 months. Medik 8, Obaji, & Aspect Dr make great formulations. If you have sensitive skin, Murad Retinol *Youth Renewal is my pick.

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Niacinamide or vitamin B3 is an important water-soluble skin vitamin. This is my go-to ingredient (in the context of anti-aging) if you have sensitive skin. Vitamin B3 has the following skin functions-

• Important role in skin barrier function
• Anti-inflammatory properties
• Immune regulation
• Potentially reduces pigmentation & wrinkles
• Potentially reduces some forms of skin cancer when taken orally.

Niacinamide can be used twice a day, starting off with a good formulation of around 10%.  B3 goes well with retinol & retinoids because it can potentially reduce skin irritation from the latter. A perfect match.

Vitamin C or ascorbic acid is a vitamin with many important roles in the skin. It can-

• Protect underlying collagen, reduce sun damage & sun burn. Ascorbic acid is the most powerful antioxidant in the skin. It also inhibits MMP or matrix metalloproteinases, enzymes that break up dermal collagen.
• Reduce pigmentation production as it inhibits melanin formation.
• Increase production of collagen, hyaluronic acid, & elastin.
• Replenish alpha tocopherol, or vitamin E, another important skin antioxidant.

Most formulations are between 10 to 20% L ascorbic acid. Vitamin C is a very unstable molecule, and hence requires special requirements in the formulation. This means the best bioavailability & stability is in an acidic environment, pH of 2.5 to 3.5. What this means clinically is that if you have sensitive skin, it may cause skin irritation.

Choosing good formulations with a concentration of around 10% can reduce irritation.

A few good brands include Obagi, Aspect Dr, Medik 8 & Skinceuticals.

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As a rule of thumb, you should start with a good cleanser & moisturizer to establish consistent barrier function. La Roche Posay & Avene makes great products for sensitive skin, including their range for dermatitis & rosacea.

The very first skincare active you should add is niacinamide. Why? Because this can reduce skin irritation & inflammation as well as build up skin barrier function. A good formulation in the 5 to 10% range is advisable.

Sunscreens should be physical, over chemical. Look for ingredients such as zinc or titanium dioxide. Invisible Zinc is good. Most patients can also tolerate hybrid sunscreens like Melan 130, La Roche Anthelios & Ultraceuticals.

Azelaic acid is another ingredient you should consider. This is an anti-inflammatory molecule that can reduce acne outbreaks, blackheads, skin inflammation from zits, rosacea & is a potent anti-pigment cream. Formulations around 10-20% are advisable.

Retinols should be attempted only when you thoroughly understand your skin’s irritant threshold. Start with a good formulation of around 0.2 to 0.5, Obaji, Skinceuticals, Murad, Aspect Dr & Medik 8 have good formulations.

If you have uber sensitive skin, you may be better off seeing a medical dermatologist for guidance. This especially applies if you suffer from rosacea, dermatitis, eczema or perioral dermatitis.

*I am a procedural dermatologist, my work is hands-on. For sensitive skin a professional diagnosis is required. This is in the realm of a medical dermatologist,  in some cases investigations such as allergic patch testing is required.

Our go to skin care acids are BHAs & AHAs. Depending on the nature of your skin we will lean towards one of the two acid washes & serums. As a guide-

BHA or salicylic acid. This acid is more lipophilic, meaning it is more suitable for patients with oily, congested or acne prone skin. Formulations include washes (2% is the most common), topicals contain 0.5 to 1%, whilst solutions are up to 5% salicylic acid.

AHAs or alpha hydroxy acids include glycolic, lactic, citric, malic & mandelic acid. These can be used in a peel (lower pH) or buffered in a skin care product. Concentrations vary depending on the formulation. A typical serum will contain 5 to 20+ percent of AHA. AHAs are great for pigmentation, pores, & fine wrinkles.

BHA & AHA serums: are great. They usually contain a lower concentration of BHA & higher amounts of glycolic & lactic acids.

Skin care takes time & patients. You will not see the results of sunscreen* & antioxidants. Put simply they are there for mitigating the side effects of UV radiation & free radicals that damage your collagen & deeper dermis.

Collagen stimulation & antiwrinkle effects from retinol, ascorbic acid & AHAs can take 3-6 months for optional results. This is because these chemicals cause a change in the messaging of cells that produce collagen, elastin & hyaluronic acid, namely fibroblasts.

Improvement in pigmentation takes around 4-8 weeks. This is because melanin pigment found in skin cells need to shed over 21 to 28 days. Older skin requires more time for shedding (exfoliation & epidermal turnover).

Anti-inflammatory ingredients such as niacinamide & azelaic acid can work faster, often within 10 to 28 days.

*Results for pigmentation however should be visible within 2-6 weeks, depending on the level of photoprotection prior.

Skin care correctors are specific ingredients used to target problems. These problems include inflammation, pigmentation, excessive oil, dry skin, or sensitive skin. The ingredient of choice depends on the cause of the problem, as well as your skin’s threshold for irritation & your current skin care routine.

As a guide-

• Pigment correctors include arbutin, licorice extract, bearberries, azelaic acid, Kojic acid, & AHAs.
• Anti-inflammatories include azelaic acid, niacinamide, green tea.
• Dry & sensitive skin will benefit from ingredients that establish barrier function. These include ceramide, squalene, hyaluronic acids, & niacinamide.

For a better understanding of skin care specifics, refer to the seconds on skin problems.

It is important to set yourself goals when you use skin care products. This may be aimed at reducing pigmentation, wrinkles, acne, or improving your skin’s luminosity. A good way to objectively measure your progress is to take photos. This gives a baseline to work from.

A good time frame is at least 6 to 8 weeks, with maximal results at 4 months. If you have not reached your goal, you may require some assistance from a skincare expert. This may be an experienced esthetician, a dermal therapist, dermatology nurse or your dermatologist. In some cases, clinical grade skin care may be a step up, with prescription skin care as the next tier. In other cases, skin directed procedures such as lasers or chemical peels may be indicated.

*Disclaimer: I do not provide skin consults as my work is entirely procedural. This means my real job is to cut, lase, peel or inject. For skin concerns, please consult my team at The Formulated.

Here is a rough guide, based upon a sensible budget. Obviously this can be less if you aim to have procedures to correct, or more if you like luxury skin care. Sometimes you can not put a dollar amount on how something makes you feel, including skin care.

• Sunscreen $30-40 per month
• Cleanser $10-15 per month
• Actives ABC $30-40 per month
• Antioxidants $20 per month

What you choose may mean a 3-5 fold difference in pricing. My view is to spend money for leave on products with good formulations, namely the ABCs & antioxidants, and spend less for wash off products like skin care acids & cleansers.

Did I forget a moisturizer? Well, that is easy, a medically oriented product from La Roche will set you back $4-9 per month.

The decision to invest more in procedures vs skincare really depends on your goals. For objective improvements, correctly prescribed skin procedures such as peels & lasers will usually better skin care products. The flipside is the feelgood factor of product application, this is subjective.

Consult one of my clinical assistants @clinccutis. They can guide you as to other small, low cost, clinically effective skin directed procedures. We have over 25 lasers & energy devices as well as over 15 clinic peels. Simple treatments that can augment & complement your current routine include-

• Chemical peels, including retinoic acid, BHA, AHA & enzyme peels.
• Lasers including Pico, Dermal Toning, Laser Genesis & Fraxel
• New generation microdermabrasion including Hydrafacial
• LED therapy
• HIFU & RF skin tightening

Disclaimer: My work is primarily surgical, filler, complex laser & peels. For skin care advice, book with my team of nurses & dermal therapists.

Biostimulation refers to stimulation of your immune system to keep producing collagen. Collagen depletes at 1-1.5% annually after the age of 20. It takes a HUGE dip around the menopausal years.

Preventing collagen loss the key to anti-aging.

Biostimulants injectables are molecules that stimulate your fibroblasts to produce more collagen. They are infinitely more effective at doing this as compared to skin care.

Depending on skin age, facial volume, skin hydration & laxity, dermatologists can select from a variety of biostimulants.

Examples include –

• High & low mol. wt hyaluronic acids
• PLLA
• PDLLA
• Polynucleotide
• PCL

Between 2-4 sessions a year. As a guide;

Year one: 4 sessions

Thereafter: 2 sessions

Injectables are classed as low level biostimulatory treatments. Ablative lasers & deep peels are high level, whist skin care is very low level biostimulator in nature.

There is some evidence that injected autologous stem cells improve skin quality. These stems are derived from adipose tissue, namely fat transfer post liposuction. Fat transfer is a treatment for volume loss due to atrophy.

Dermatologists & plastic surgeons agree that there are other procedures that can give a more predictable anti-ageing benefit, for example dermal fillers, collagen stimulating fillers, & skin directed therapy such as lasers, peels & basic simple skin care.

I do believe that stem cell skin therapy will improve however at the time of writing, we do not have predictable & reproducible protocols for anti-ageing.

If you would like to consider stem cells in your skincare routine, you can ask my nurses or dermal therapist regarding mesenchymal stem cells, alternatively you can buy them online. I do not stock stem cell at The Formulated, simply because the scientific evidence is not strong enough to justify the use (as of 2021, I may change my mind based upon scientific literature).