Alpha Hydroxy for Skin Care
Baby boomers and others who once sought the sun's rays with little thought of skin damage are now paying the price—billions of dollars annually for cosmetics containing alpha hydroxy acids (AHAs). Derived from fruit and milk sugars and served up in creams and lotions, AHAs attract customers with their supposed ability to reduce wrinkles, spots, and other signs of sun-damaged skin. Some scientific evidence suggests they may work.
But are these products safe? Since 1989, the US Food and Drug Administration (FDA) has received more than 100 reports of adverse reactions in people using AHA products. Their complaints included severe redness, swelling (especially in the area of the eyes), burning, blistering, bleeding, rash, itching, and skin discoloration.
The FDA believes reactions from AHAs are probably even more widespread. Past experience suggests that for every adverse reaction report the agency receives, the manufacturer receives 50 to 100. "This would translate into approximately 10,000 adverse reactions being received for AHA-containing products," says John Bailey, PhD, former director of the FDA's Office of Cosmetics and Colors.
Also, the product's relative newness—widely available since about 1992—means that its long-term effects are unknown. An industry-sponsored study found that people who use AHA products have greater sensitivity to sun, increasing the risk of photoaging and ]]>skin cancer]]>.
"There are many unanswered questions in front of us," Bailey says. "AHAs are unlike anything else ever introduced onto the cosmetic market on such a wide scale. They are not your traditional cosmetics."
While we to find out what the long-term effects of AHAs are, the FDA cautions consumers to take extra care with these products. For example, avoid the sun when possible, use adequate sun protection, and report adverse reactions immediately to doctors or directly to the FDA.
AHAs Are Everywhere
AHA cosmetics are believed to have derived from the "chemical peels" that dermatologists and plastic surgeons have used for years. The peels help remove undesirable signs of skin aging, such as discoloration, roughness, and wrinkling. The chemicals cause the skin to lose its outer layer, or peel off, revealing a fresher-looking layer of skin. Known as chemical exfoliation, the procedure is done in doctors' offices so that doctors can control the process and prevent deep skin burns from the highly acidic solutions. Other applications for AHAs include stretch marks, mosquito repellant, postinflammatory hyperpigmentation, and psoriasis.
Cosmetic manufacturers began to market similar but milder versions of these chemical peels containing AHAs for salon and at-home use around 1989. The products quickly caught on, and today, says Lisa Berger, a cosmetic sales manager for a Hecht Co. department store in Washington, DC, "Every [cosmetic company] has AHA products. There used to be only three product lines; now there are 20."
The AHAs used most often in cosmetics are glycolic acid and lactic acid, although there are others. Increasingly, says Zoe Draelos, MD, a dermatologist in High Point, NC, manufacturers are using poly-AHAs, which have larger molecules, and beta hydroxy acids (BHAs), such as salicylic acid, an ingredient in aspirin. According to Draelos, who consults for several large US cosmetic companies, these products may produce less skin irritation.
Typically, AHA products sold to consumers have an AHA concentration of 10% or less. The concentration of AHA products used by trained cosmetologists may run between 20% and 30%, while those used by doctors can range from 50%-70%.
Though sold to consumers mainly in face and body creams and lotions, AHAs also can be found to a lesser degree in other cosmetics, such as shampoos and cuticle softeners. Available everywhere, from discount pharmacies to fine department stores, the products typically range in price from a few dollars to more than $60 a bottle.
Some in the cosmetic industry have suggested that AHA products are more than simple cosmetics, coining the term "cosmeceutical" to describe them instead.
Under the 1938 Federal Food, Drug, and Cosmetic Act, cosmetics are defined as "articles intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body or any part thereof for cleansing, beautifying, promoting attractiveness, or altering the appearance." Drugs are defined as products intended for treating or preventing disease and affecting the structure or any function of the body. They are subject to premarket review and approval; cosmetics are not.
"The term 'cosmeceutical' is not recognized by law," Bailey says. "These products, depending on their intended use, would be regulated either as cosmetics, drugs, or both as cosmetics and drugs."
The FDA has a particular concern about AHAs because, unlike traditional cosmetics, AHAs seem capable of penetrating the skin barrier. In reviewing the data on AHAs, the FDA concluded in a 1996 report that certain formulations of AHA products can affect the skin in a manner similar to that of chemical peels—that is, increasing cell turnover rate and decreasing the thickness of the outer skin. The effect depends on the product's pH level (a measure of its acidity), the AHA concentration, and the AHA vehicle cream, as well as how the product is used (for example, frequency of use and where on the skin it is applied).
Additional concern arose in 1996 when some people who had reported adverse reactions cited increased sun sensitivity. In addition, one industry-sponsored study found that participants whose skin was exposed to 4% glycolic acid twice daily for 12 weeks developed some skin redness with 13% to 50% less UV exposure than normal.
Another study that looked at the effects of glycolic acid on production of sunburn cells (markers for UV-induced skin damage) found that people who received the AHA product in the presence of UV radiation experienced twice the cell damage in areas where the AHA had been applied than those who were treated with the non-AHA product.
In 2000, two studies sponsored by the FDA's Office of Women's Health confirmed that AHA makes people's skin more susceptible to sun damage, but this change was quickly reversible when AHA was discontinued.
The FDA intends to complete a photocarcinogenicity study of AHAs in a newly established testing facility in a study that began in 2000. The concern is that people who are sensitive to sunlight may be particularly susceptible to UV rays, which can damage the skin and, over a long period, can cause skin cancer.
In 1997, the Cosmetic Ingredient Review Panel, the cosmetic industry's self-regulatory body for reviewing and addressing safety of cosmetic ingredients, concluded that the AHA's glycolic acid and lactic acid and their related chemical compounds are safe for use in products intended for consumer use when:
- The AHA concentration is 10% or less.
- The final product has a pH of 3.5 or greater (lower numbers indicate greater acidity).
- The final product is formulated in such a way that it protects the skin from increased sun sensitivity or its package directions tell consumers to use sunscreen products.
For AHA products used by trained cosmetologists, the Cosmetic Ingredient Review Panel concluded that formulations of glycolic acid and lactic acid at concentrations of 30% or less and a pH of 3.0 or greater intended for only "brief" use at one time followed by thorough rinsing and daily use of sun protection are safe.
The panel's conclusions actually serve as guidelines for cosmetic manufacturers, Bailey says. "This means that each manufacturer of an AHA product should conduct appropriate testing on their products to measure whether or not the product increases the sensitivity of the user to UV radiation and, if so, should add sun protection to their product and warn consumers to take extra steps to protect themselves at all times."
Meanwhile, studies of AHA safety continue. Depending on the outcome of these investigations, Bailey says, the agency may or may not take action against AHA products. "The absence of action by FDA to date doesn't mean that there won't be any in the future."
Reading the Label
Here are some ingredient terms that indicate a cosmetic contains alpha or beta hydroxy acids.
Alpha hydroxy acids :
- glycolic acid
- lactic acid
- malic acid
- citric acid
- glycolic acid + ammonium glycolate
- alpha-hydroxyethanoic acid + ammonium alpha-hydroxyethanoate
- alpha-hydroxyoctanoic acid
- alpha-hydroxycaprylic acid
- hydroxycaprylic acid
- mixed fruit acid
- triple fruit acid
- tri-alpha hydroxy fruit acids
- sugar cane extract
- alpha hydroxy and botanical complex
- L-alpha hydroxy acid
- glycomer in crosslinked fatty acids alpha nutrium
Beta hydroxy acid :
- salicylic acid
In 2002, the FDA proposed a new label that would be required on products containing AHAs. If approved, the label will read: "Sunburn Alert: This product contains an alpha hydroxy acid (AHA) that may increase your skin's sunburn. Use a sunscreen and limit sun exposure while using this product and for a week afterwards."
Approved Treatments for Signs of Sun-Damaged Skin
The following products have been studied for safety and effectiveness and approved by the FDA for treating signs of sun-damaged skin:
]]>Renova]]> (tretinoin emollient cream) – This vitamin A derivative, available by prescription only, is approved for reducing the appearance of fine wrinkles and mottled darkened spots and roughness of facial skin in people whose skin does not improve with regular skin care and use of sun protection. Renova does not eliminate wrinkles, repair sun-damaged skin, or restore skin to its healthier younger structure. Also, the safety of daily Renova use for longer than 48 weeks has not been established, and it should not be used by women who are pregnant or trying to become pregnant. Renova has not been studied in people 50 and older or in people with moderately or darkly pigmented skin.
Carbon dioxide (CO2) and Erbium:YAG (Er:YAG) lasers – These medical devices are approved for treating wrinkles. The procedure requires removal of facial skin in a layer-by-layer manner. It is performed under anesthesia by a doctor in an outpatient surgical setting.
Milder fractionated laser resurfacing techniques have recently been FDA approved for the treatment of sun damaged skin.
Note that the Botulism toxin has been approved for wrinkles but not for sun-damaged skin.
Use With Care
Considering the questionable safety status, the FDA and dermatologists advise consumers who use AHA products to follow these precautions:
- Always protect your skin before going out during the day.
- Use a sunscreen product with an SPF (Sun Protection Factor) of at least 30.
- Wear a hat with a brim of at least four inches (about 10 centimeters).
- Cover up with lightweight, loose-fitting, long-sleeved shirts and pants.
- Buy products with adequate label information. For example, read the list of ingredients to see which AHA or other chemical acids are in the product. Pay attention to the name and address of the manufacturer or distributor, which can serve as the contact if a problem or question arises, as well as a statement about the product's AHA concentration and pH level. The first two pieces of information are mandatory, while the third is optional. Consumers can call or write the manufacturer to get information about a product's AHA concentration and pH level.
- Buy only products that comply with the Cosmetic Ingredient Review Panel's 1997 recommendations, that is, products with an AHA concentration of 10% or less and a pH of 3.5 or greater.
- Do a skin-sensitivity test on a patch of skin if you are a first-time user of any AHA product or are using a different brand or a product with a different concentration or pH than you are used to.
- Stop using the product immediately if you experience adverse reactions. Signs of adverse reactions include stinging, redness, itching, burning, pain, and bleeding or change in sun sensitivity. Even mild irritation is a sign that the product is causing damage. Despite what the manufacturer may indicate on the product label, "Cosmetics shouldn't sting or cause irritation," Bailey adds.
If you have an adverse reaction, see a dermatologist. A dermatologist can tell you whether an adverse reaction is from the product or is an indication of an underlying disease, such as skin cancer. Dermatologists also can recommend appropriate skin-care products. They can report your case, keeping your name confidential, to the FDA's adverse reaction monitoring program.
You also can report your adverse reaction yourself to the FDA . "We'd like to know about it even if it's only a mild reaction," Bailey says.
Bailey adds that these precautions are important until AHAs' safety is better known. "We are told that AHAs are here to stay," he says. "But they are not reviewed for safety before they are put on the market. And we don't have enough information to say that they are safe."
Food and Drug Administration
American Academy of Dermatology
Food and Drug Administration, Center for Food Safety and Applied Nutrition website. Available at: http://www.cfsan.fda.gov/ . Accessed August 1, 2003
Food and Drug Administration website. Available at: http://www.fda.gov/
FDA and the European Commission's Enterprise Directorate General Bilateral Meeting: Cosmetics "Breakout'" Meeting. Food and Drug Administration website. Available at: http://www.cfsan.fda.gov/~dms/cosint99.html . Accessed January 5, 2004.
Ash K, Lord J, Zukowski M, et al. Comparison of topical therapy for striae alba (20% glycolic acid/0.05% tretinoin versus 20% glycolic acid/10% L-ascorbic acid). Dermatol Surg. 1998;24:849-856.
Last reviewed January 2009 by ]]>Mervin Low, MD, PC ]]>
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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