Customize your JAMA Network experience by selecting one or more topics from the list below.
Clean beauty, also known as natural skin care, is having a moment. From 2017 to 2018, the natural skin care market grew by 23% to 1.6 billion dollars, accounting for over 25% of the 5.6 billion dollars of annual skin care sales in 2018.1 Staunch warnings from influencers such as Gwyneth Paltrow, whose blog Goop warns readers “Do you want antifreeze (propylene glycol) in your moisturizer? We’re going to guess no,”2 have ignited fear in consumers who are now hungry for skincare that is safe and nontoxic. However, the US Food and Drug Administration (FDA) has failed to define clean and natural, leaving these labels open to interpretation by nondermatologist retailers, bloggers, and celebrities who have set out to define clean beauty for themselves. While the clean beauty movement has demonized hundreds of compounds, in this Viewpoint, we argue that an arbitrary designation of clean or natural does not necessarily make products safer for consumers.
Many of the ingredients that have been denounced by clean beauty evangelists seem to be selected haphazardly as companies attempt to “greenwash” their products to make them more attractive to conscientious shoppers. In July 2018, for example, Whole Foods released its updated list of unacceptable ingredients, which lists over 400 compounds they feel are unfit for their line of premium body care.3 Their list of banned ingredients includes petrolatum, which dermatologists have consistently recommended to patients with skin barrier disruption owing to its nonallergenicity, superior qualities as a humectant, and economical cost that makes it accessible to patients of all backgrounds. The Campaign for Safe Cosmetics advocates for consumers to avoid a multitude of ingredients including parabens,4 which the American Contact Dermatitis Society named 2019 nonallergen of the year.5 Parabens are some of the least allergenic preservatives available, with rates of contact sensitization between 0.5% to 1.4%—rates that have been stable since the 1990s.6 The Environmental Working Group’s (EWG) safe skin database warns consumers against exposure to chemical sunscreen ingredients,7 though a recent editorial in JAMA8 explains that although there is evidence of systemic absorption of sunscreen ingredients, we do not yet have data to link this systemic absorption with toxic or adverse effects, and that sunscreens remain critical in our defense against keratinocytic skin cancers.
Additionally, many so-called natural products contain high concentrations of botanical extracts that are a leading cause of both irritant and allergic contact dermatitis and photosensitization.9 In a study done by the University of Ferrara, 6.22% of topical herbal product users reported 1 or more adverse cutaneous reactions, with a prevalence higher in women than men.10 While Goop states that “the worst offenders are preservatives that release formaldehyde, a known human carcinogen and potent skin irritant and allergen,”11 large-scale studies across Europe and the United States investigating the rates of contact dermatitis to common preservatives show that the preservatives most frequently implicated in contact sensitization are isothiazolinones, including methylchoroisothiazolinone and methylisothiazolinone, which are not formaldehyde releasers.12,13 With a sensitization rate greater than 4%, isothiazolinones are the most common cause of contact dermatitis to preservatives in Europe.12 Alternative preservatives with lower rates of contact sensitization include formaldehyde and formaldehyde releasers, parabens, and iodopropynyl butylcarbamate. The prevalence of contact allergy to formaldehyde ranges from 1% in Europe to 7% in the United States, while the prevalence of contact allergy to formaldehyde releasers such as quaternium-15, diazolidinyl urea, imidazolidinyl urea, 1,3-dimethylol-5,5-dimethylhydantoin, and 2-bromo-2-nitropropane-1,3-diol (bronopol) ranges from less than 1% in Europe to between 0.5% and 2% in the United States. Contact sensitization rates for iodopropynyl butylcarbamate have been reported to range from 1.2% to 4.2%.6,12 The natural skin care movement’s intolerance of parabens and other safer preservatives has unintended consequences, such as the use of more allergenic preservatives such a methylisothiazolinone. This unwarranted avoidance of low-allergen and safe preservatives and increased use of botanicals has been associated with a new epidemic of contact dermatitis, which is responsible for high medical bills, time away from work and family, and a diminished quality of life.13,14
In general, it seems that sulfates, parabens, formaldehyde releasers, chemical sunscreens, fragrance, butylated hydroxytoluene, phthalates, and propylene glycol are skin care components that are consistently banned by the natural skin care movement. While it is imperative for patients with contact dermatitis to avoid any ingredients they are sensitized to, many of the strongest voices in the clean beauty movement suggest avoiding ingredients owing to a theoretical risk of endocrine disruption and cancer, despite the fact that a causative relationship between these disease states and the concentration of these ingredients in cosmetic products has not been proven scientifically.5 In the same way that the antivaccine movement often fails to acknowledge the success of vaccines in promoting population health, it is easy to forget that the use of safe preservatives such as parabens and formaldehyde releasers is necessary to prevent severe infections and complications such as the Pseudomonas-induced corneal ulcers reported in the 1970s from inadequately preserved mascara.15,16
At this point in time, there seems to be discordance between what dermatologists know about the science of the skin and what is being disseminated to consumers through the clean beauty movement. The EWG’s safe skin database scores thousands of products based on the putative toxicity of their ingredients,17 but these claims are not always uniformly agreed on by a broad consensus of experts, and can cause confusion to consumers. For example, the EWG has assigned a hazard score of 5 (moderate hazard) to the common ingredient PEG-2 soyamine, despite acknowledging that, “data available: none.”18 Although the EWG remains a powerful force driving the clean beauty dialogue, their method for assessing risk does not seem to be data driven. The EWG also profits from participating in affiliate programs where they receive a percentage of the sale when a consumer makes a purchase through their website, which may be a notable conflict of interest. The Cosmetic Ingredient Review (CIR), on the other hand, is an alternative resource, which consists of experts in a number of disciplines including dermatology and toxicology. Claims made by the CIR are backed by scientific evidence that is visible to readers. After extensive review of the evidence, they determined that propylene glycol, parabens, sulfates, and many other ingredients demonized by the clean beauty movement were nontoxic and noncarcinogenic.19
Dermatologists need to be educated on the science of skin care ingredients so that when patients inevitably ask us about natural skin care, we can explain that natural is a marketing term that does not necessarily mean safer or more effective. Misinformation may lead to higher rates of contact dermatitis, substantial financial investment into natural products encouraged by companies with a clear financial conflict of interest, and unnecessary avoidance of safe and necessary skin care ingredients. Additionally, we urge the FDA to consider defining clean and natural to prevent consumer misconceptions about what these terms mean. Finally, both consumers and physicians should demand that the clean beauty movement back up their claims with evidence.
Corresponding Author: Bruce Brod, MD, MBE, Department of Dermatology, University of Pennsylvania, 3600 Spruce St, 2 Maloney Building, Philadelphia, PA 19104 (email@example.com).
Published Online: September 25, 2019. doi:10.1001/jamadermatol.2019.2724
Conflict of Interest Disclosures: None reported.
Identify all potential conflicts of interest that might be relevant to your comment.
Conflicts of interest comprise financial interests, activities, and relationships within the past 3 years including but not limited to employment, affiliation, grants or funding, consultancies, honoraria or payment, speaker's bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued.
Err on the side of full disclosure.
If you have no conflicts of interest, check "No potential conflicts of interest" in the box below. The information will be posted with your response.
Not all submitted comments are published. Please see our commenting policy for details.
Rubin CB, Brod B. Natural Does Not Mean Safe—The Dirt on Clean Beauty Products. JAMA Dermatol. 2019;155(12):1344–1345. doi:10.1001/jamadermatol.2019.2724
Create a personal account or sign in to: