Written by Dr Anjali Mahto
Skincare has become more complex without becoming more intelligent. Ingredient lists are longer, formulations more intricate, and scientific language more visible than at any point in the past, yet many patients feel increasingly confused, more reactive, and less confident about what their skin actually needs. This paradox has little to do with a lack of effective treatments. It reflects a widening gap between how skincare is discussed publicly and how dermatologists think and practise in clinical settings.
In dermatology, skincare is not constructed by accumulating ingredients, nor is it driven by novelty, trend cycles, or marketing claims. It is built around mechanisms: how ultraviolet radiation alters dermal structure and accelerates ageing, how inflammation disrupts follicular behaviour and perpetuates acne, how pigment is produced, transferred, and retained, and how the integrity of the epidermal barrier governs tolerance, sensitivity, and long-term outcomes. Ingredients are tools within this framework. Their value lies in how reliably they influence these biological processes over time, not in how new, complex, or fashionable they appear.
Much of the skincare content available to patients does not reflect this logic. Instead, it is product-led, commercially driven, or organised around isolated concerns treated as separate problems. Even when well-intentioned, it frequently blurs the distinction between ingredients supported by decades of robust clinical evidence and those whose benefits are inferred from small, short-term, or formulation-specific studies. Patients are encouraged to rotate products frequently, layer multiple actives without a clear rationale, and interpret irritation as evidence that something is “working”. The outcome is predictable. Skin becomes inflamed, tolerance decreases, results plateau, and trust erodes.
In December 2025, a large Delphi consensus study published in the Journal of the American Academy of Dermatology attempted to address this confusion directly. Rather than asking which ingredients were popular or commercially successful, the authors asked a far more clinically meaningful question: which topical skincare ingredients do expert cosmetic dermatologists actually recommend, in real practice, for the skin concerns they treat most often. This guide synthesises the findings of that consensus alongside more than three decades of published clinical data, distilling hundreds of ingredients and studies into a single, coherent framework that reflects how consultant dermatologists actually practise.
The methodology of the study is central to its authority. The authors began with a comprehensive literature search spanning publications from 1990 onwards, identifying 318 discrete, generic cosmetic ingredients used in both prescription and over-the-counter skincare. These were not brand formulations but individual actives intended to modify skin biology. A senior panel of board-certified cosmetic dermatologists reviewed these lists and selected ingredients they considered genuinely useful in routine clinical practice. Only those nominated by more than one expert progressed, substantially narrowing the field.
A second panel of sixty-two academic cosmetic dermatologists across forty-three institutions then participated in a formal two-round Delphi process. Participants rated how likely they were to recommend each ingredient for each specific concern on a nine-point scale, ranging from strong discouragement to strong recommendation. Between rounds, a structured consensus meeting addressed disagreement, clarified definitions, and refined the lists. Only ingredients achieving at least a seventy per cent strong recommendation with minimal dissent were accepted. Following consensus, the authors reviewed and graded the supporting clinical evidence using established Oxford Centre for Evidence-Based Medicine criteria.
The outcome was deliberately restrained. Out of hundreds of ingredients in circulation, only twenty-three met the threshold for consistent expert recommendation across seven common concerns: fine lines and wrinkles, acne, redness, dark spots, large pores, dry skin, and oily skin. Many of these ingredients have been used for decades. Several are newer, but mechanistically well understood and supported by controlled clinical studies. A large number of heavily marketed ingredients did not reach consensus, largely because the available studies were small, short-term, formulation-specific, or insufficient to support routine clinical use across common indications.
This restraint is precisely what makes the findings useful. It reflects how dermatology advances in reality: through reproducible outcomes, long-term safety data, and predictable benefit rather than rapid innovation cycles. Understanding this consensus through a clinical lens helps explain why many skincare routines fail despite appearing sophisticated.
One of the most common reasons skincare fails is the absence of diagnosis. Redness may reflect rosacea, eczema, barrier dysfunction, photodamage, or fixed vascular change. Pigmentation may be melasma, post-inflammatory hyperpigmentation, lentigines, or a combination. Acne may be comedonal, inflammatory, hormonally driven, medication-related, or mechanically exacerbated. The same ingredient will not perform equally across these patterns, even if the surface appearance looks similar.
A second reason is the misinterpretation of irritation as efficacy. Tingling, peeling, and tightness are often framed as positive signs, when clinically they signal barrier disruption and escalating inflammation. A third reason is inconsistency. Most evidence-based ingredients act slowly, through cumulative biological change. Routines that are constantly escalated, abandoned, or restarted rarely produce stable results.
Against this background, the consensus around ageing and photodamage is unsurprising. For fine lines and wrinkles, the most consistently recommended ingredients were sunscreen, retinoids, vitamin C, and chemical sunscreen. This reflects decades of high-quality evidence demonstrating that ultraviolet radiation is the dominant driver of premature skin ageing and that consistent photoprotection reduces both clinical and histological signs of dermatoheliosis. Randomised trials show that daily sunscreen use slows wrinkle formation, improves texture, and reduces markers of photodamage over time.
The consensus does not frame mineral and chemical sunscreens as competing ideologies. Both provide effective ultraviolet protection. What matters clinically is broad-spectrum coverage, adequate application, and daily adherence. For patients prone to pigmentation or sensitivity, mineral or tinted formulations may be better tolerated and offer protection against visible light, which is increasingly recognised as relevant in melasma and other pigmentary disorders. This nuance is often lost in popular discourse but is clinically important for relapse prevention.
Retinoids form the second cornerstone of ageing management and, more broadly, of evidence-based skincare. They are among the most extensively studied topical agents in dermatology, with high-quality evidence supporting their use across multiple concerns: fine lines, acne, pigmentation, large pores, and oily skin. Their biological effects explain this breadth. Retinoids stimulate collagen synthesis, increase epidermal turnover, normalise keratinisation, reduce inflammation, and influence melanin distribution within the epidermis. No other topical ingredient demonstrates comparable reach across so many pathways.
Despite this, retinoids are one of the most commonly failed treatments in practice. Failure is rarely due to inefficacy. It is almost always due to intolerance caused by overly aggressive initiation, inadequate barrier support, or unrealistic expectations of speed. Long-term success depends far more on tolerance and consistency than on maximal concentration. Lower strengths, reduced frequency, and careful sequencing allow the skin to adapt over months rather than weeks. This principle applies equally to cosmetic retinoids and prescription formulations.
Vitamin C completes the foundation for photodamage management. Meta-analyses and controlled trials support its role in reducing ultraviolet-induced skin ageing, improving fine lines, and enhancing dermal collagen markers. It also appears in the consensus for hyperpigmentation, reflecting its ability to inhibit melanin synthesis and provide antioxidant protection. Vitamin C is best understood as a supportive ingredient that strengthens a routine anchored in photoprotection and retinoids rather than as a standalone solution.
Acne and oiliness represent a shift from photodamage to follicular disease. Acne is a chronic inflammatory condition involving abnormal keratinisation, microbial proliferation, and immune signalling within the pilosebaceous unit. The consensus ingredients for acne were retinoids, benzoyl peroxide, salicylic acid, clindamycin, azelaic acid, and glycolic acid. Each targets a different aspect of acne biology.
Benzoyl peroxide remains one of the most clinically valuable acne treatments available. Randomised controlled trials demonstrate reductions in both inflammatory and non-inflammatory lesions, and critically, it does not induce bacterial resistance. When used alongside topical antibiotics, it reduces resistance risk and improves outcomes. Lower concentrations are often as effective as higher ones, with fewer side effects, a point frequently overlooked in consumer skincare.
Topical clindamycin reached consensus when used appropriately, reflecting evidence that combination therapy with benzoyl peroxide outperforms antibiotic monotherapy and aligns with
good antimicrobial stewardship. Salicylic acid was endorsed for its comedolytic properties and ability to penetrate oil-filled follicles. It is particularly useful for comedonal congestion and oily skin, though it does not replace retinoids in moderate inflammatory acne.
Azelaic acid occupies a uniquely versatile position. It is supported by evidence for inflammatory acne, reduces bacterial proliferation, modulates keratinisation, and inhibits tyrosinase, making it valuable for patients who develop post-inflammatory hyperpigmentation. Its tolerability profile means it is often suitable for patients who cannot tolerate stronger actives. Glycolic acid reached consensus for acne and dark spots, supported by split-face and comparative trials, but its role is selective. Overuse, particularly alongside retinoids, is a common cause of barrier breakdown and rebound inflammation.
Oily skin was considered separately. Retinoids, benzoyl peroxide, and salicylic acid were recommended, reflecting their ability to normalise follicular behaviour rather than simply remove surface oil. The evidence base for direct sebum suppression remains limited, and the consensus reflects this uncertainty. Clinically, aggressive oil-stripping often worsens oiliness by increasing irritation and inflammatory signalling.
Redness and sensitivity represent an area where skincare becomes explicitly diagnostic. The consensus ingredients included sunscreen, sulfacetamide-sulfur, metronidazole, ivermectin, brimonidine, niacinamide, and green-tinted products. Several of these are prescription agents commonly used in rosacea, reflecting the fact that persistent facial redness is often inflammatory or vascular rather than simply “sensitive skin”. Clinical trials support the efficacy of metronidazole, ivermectin, and sulfacetamide-sulfur in reducing erythema and inflammatory lesions. Brimonidine acts as a vasoconstrictor, reducing visible redness rapidly, but without addressing underlying inflammation. Niacinamide appears as a non-prescription option with evidence supporting anti-inflammatory effects and barrier support. Green-tinted products were included as optical camouflage rather than treatment, acknowledging the psychosocial impact of visible redness while medical therapy takes effect.
Pigmentation is one of the most challenging concerns and one where aggressive routines often backfire. The consensus ingredients for dark spots included hydroquinone, retinoids, vitamin C, azelaic acid, glycolic acid, kojic acid, tranexamic acid, and niacinamide. Hydroquinone remains the most effective topical lightening agent, supported by robust clinical trials, but tolerability and relapse risk mean it is often best used in supervised courses rather than indefinitely.
Tranexamic acid represents a significant modern addition, with evidence demonstrating comparable efficacy and lower irritation risk, making it suitable for long-term management.
The central clinical principle in pigmentation management is stability. Pigment improves when inflammation is controlled, the barrier is intact, and photoprotection is consistent. Over-exfoliation and indiscriminate layering are among the most common triggers of worsening pigmentation, particularly in darker skin tones. Visible light protection, often overlooked, plays an important role in melasma relapse prevention.
Large pores were treated conservatively. Retinoids were the only ingredient to reach consensus, reflecting evidence that they improve pore appearance by normalising keratinisation and stimulating dermal support. Many products claim to shrink pores temporarily. Retinoids are recommended because they address the underlying biology rather than surface optics.
Dry skin and barrier repair complete the picture. The consensus ingredients were petrolatum, ceramides, hyaluronic acid, urea, and ammonium lactate. These ingredients are supported by evidence showing improvements in hydration, reductions in transepidermal water loss, and restoration of barrier integrity. They are not glamorous, but they are effective. Barrier repair is not optional. It determines tolerance of every other active in a routine and underpins long-term skin stability.
Equally important is what the consensus did not endorse. Ingredients such as growth factors, peptides, and DNA repair enzymes, despite their prevalence in cosmetic formulations, did not achieve consistent recommendations, largely because the evidence remains insufficient, inconsistent, or formulation-specific. This reflects how dermatologists practise. Ingredients earn their place through reproducible outcomes and long-term data, not through marketing cycles.
One of the striking conclusions of the 2025 consensus is not how much has changed, but how little. Despite an explosion of new products and marketing language, the core ingredients consistently recommended by dermatologists remain largely unchanged from those discussed in The Skincare Bible. Sunscreen, retinoids, benzoyl peroxide, azelaic acid, vitamin C, hydroquinone, and barrier-repair agents continue to form the foundation of effective skincare.
What has evolved are delivery systems, formulation tolerability, and the strength of evidence for selected newer agents such as tranexamic acid. The underlying hierarchy of what works, what is optional, and what remains unproven has not fundamentally shifted. The perception of rapid progress reflects noise rather than a wholesale change in evidence.
Understanding this continuity is often reassuring. It explains why a routine that prioritises photoprotection, retinoid use, and barrier support remains effective year after year, while constantly changing products often leads to irritation without meaningful improvement. It also explains why good dermatology rarely feels radical. When skincare works, it does so quietly, predictably, and over time.
What does an evidence-based skincare routine look like?
A good skincare routine is not defined by the number of products it contains, nor by how aggressively it targets every possible concern at once. It is defined by coherence. Each step should have a clear purpose, and each ingredient should earn its place by addressing a mechanism that matters for that individual’s skin.
From a dermatological perspective, most effective routines share the same underlying structure, even when the specific products differ. In the morning, the priority is protection and stability. Cleansing should be gentle and functional rather than corrective. Over-cleansing increases irritation and disrupts the barrier, particularly in acne-prone or pigment-prone skin. A moisturiser is used when needed to support barrier integrity, not because hydration itself is an active treatment.
Vitamin C may be introduced if it is tolerated and if the goal includes protection against photodamage or pigment modulation, but it is optional rather than mandatory. The single non-negotiable step is sunscreen. Broad-spectrum ultraviolet protection, applied daily and in adequate quantity, underpins every other intervention discussed here.
In the evening, the focus shifts from protection to modification. This is where most routines succeed or fail. Retinoids form the backbone of evening skincare for ageing, acne, pigmentation, pores, and oiliness. They should be introduced slowly, at a frequency and strength the skin can tolerate, and supported by adequate moisturisation. Escalation should be gradual and guided by tolerance rather than impatience. The aim is not rapid change, but sustained adaptation over months.
Additional actives are layered only when there is a clear indication. In acne-prone skin, benzoyl peroxide or salicylic acid may be added strategically, often as wash-off or targeted treatments rather than all-over nightly use. In pigment-prone skin, agents such as azelaic acid or tranexamic acid may be incorporated once inflammation is controlled and the barrier is stable. In sensitive or redness-prone skin, barrier repair and anti-inflammatory strategies take precedence over aggressive exfoliation or turnover-driven approaches.
What distinguishes a good routine from an ineffective one is restraint. Actives are not piled indiscriminately. New products are not introduced simultaneously. Irritation is treated as a signal to pause and simplify rather than as evidence of progress. When routines fail, it is rarely because the wrong ingredient was chosen. It is because too many mechanisms were targeted at once, or because the skin was not given time to adapt.
Taken together, this consensus does not provide a routine to copy. It provides a hierarchy of evidence that explains why certain ingredients recur across conditions and why others fall away despite popularity. In practice, the challenge is rarely a lack of information or products. It is identifying which pathways matter most for an individual patient and sequencing treatment in a way the skin can tolerate. Two patients with acne, redness, or pigmentation may require entirely different approaches, even when the same ingredients are involved.
This is where consultant-led assessment changes outcomes. In practice, effective skincare depends less on copying a routine and more on identifying which pathways are relevant for an individual’s skin and sequencing treatment accordingly. At our dermatology clinic in London, this process is built into how care is delivered, beginning with structured assessment and objective skin analysis where appropriate, and escalating to medical input when indicated. For patients who recognise these patterns in their own experience, this approach offers a way to move beyond prolonged trial and error.
Reference Alvarez GV, Kang BY, Richmond AM, et al. Skincare ingredients recommended by cosmetic dermatologists: A Delphi consensus study. Journal of the American Academy of Dermatology. 2025;93:1509–1525.
