Volume 16 | Issue 9
Cosmetic Practitioners Take Huge Risks Purchasing and Administering Illegal Botulinum Toxin Drug Products
Sheldon Bradshaw JD|In their article “Importing Injectables” in the September 2014 issue of the Journal of Drugs in Dermatology, Dr. Kenneth Beer and Karen Rothschild highlighted the possible harm to patients and practitioners from the use of unapproved botulinum toxin products – eg, Botox, Dysport, Xeomin, and Myobloc – and other cosmetic prescription drug products purchased from foreign or unlicensed suppliers.1 In the intervening years, the accuracy of their critique has been repeatedly demonstrated, as the dangers to patients’ health, as well as to cosmetic practitioners’ liberty, has only increased.
Ralph P. Braun MD,a Sabine Ludwig MD,a Ashfaq A. Marghoob MDb|
Seborrheic keratosis (SK) is a benign epidermal keratinocytic tumor that is extremely common, particularly in individuals over the age of 50. Most individuals with SK will have more than one lesion and the presence of over 10 lesions in the same person is not uncommon. Although the clinical morphology of most SK with their stuck-on, symmetric, keratotic, and waxy appearance makes them easy to identify, many manifest a morphology resembling melanoma or squamous cell carcinoma. One can argue that such cases will ultimately not prove to be problematic since a simple biopsy will easily reveal their benign nature and eliminate any concerns. However, the cost and morbidity associated with the biopsy of benign lesions should not be underestimated. Methods to improve our in vivo ability to correctly identify SK will prove beneficial not only to the health care system in general but to the individual patient specifically. The issue of greater concern resides with skin cancers that mimic SK or when skin cancers arise in association with SK. Needless to say, in vivo methods to help identify malignancy and differentiate them from benign lesions would be welcomed by all. Fortunately, we do now have in vivo imaging methods such as dermoscopy that can improve the clinician’s diagnostic accuracy. In this article, we summarize the current knowledge regarding the clinical and dermoscopic features of SK, and provide clues to aid in their diagnosis.
J Drugs Dermatol. 2017;16(9):835-842.
Marina Landau MD,a Chytra V. Anand MD,b Thierry Besins MD,c Yates Yen Yu Chao MD,d Sabrina Guillen Fabi MD FAAD FAACS,e Uliana Gout MD,f Martina Kerscher MD PhD,g Tatjana Pavicic MD,h Peter Hsien Li Peng MD,i Berthold Rzany MD ScM,j Gerhard Sattler MD,k Tunk Tiryaki MD,l Heidi A. Waldorf MD,m and Andre Braz MDn|BACKGROUND: Facial aging is a complex interplay of extrinsic and intrinsic factors leading to progressive changes in the skin, subcutaneous tissue, and bone. Clinical experience suggests that early aesthetic intervention may slow the signs of aging, but treatment in the absence of symptoms or with minimal signs of aging has not yet been properly addressed. OBJECTIVES: To provide treatment recommendations for primary prevention and early intervention in individuals with no or minimal signs of aging. METHODS: Fourteen specialists in aesthetic medicine convened over a full-day meeting under the guidance of a certified moderator. RESULTS: Tailored treatment recommendations have been provided for prevention and early intervention of fine wrinkles, static lines and folds, irregular pigmentation, laxity, and subcutaneous volume loss by protecting the epidermis, stimulating neocollagenesis, reducing hyperkinetic musculature, and reinforcing supporting structures. CONCLUSION: Preventive measures and early therapeutic interventions that may alter the course of facial aging were defined. Further studies are needed to support these recommendations with the best possible evidence.
J Drugs Dermatol. 2017;16(9):846-854.
Communication Concepts for Prevention and Early Intervention in Aesthetic Medicine: Consensus and Literature Review
Uliana Gout MD,a Chytra V. Anand MD,b Andre Braz MD,c Yates Yen Yu Chao MD,d Sabrina Guillen Fabi MD FAAD FAACS,e Martina Kerscher MD PhD,f Marina Landau MD,g Tatjana Pavicic MD,h Peter Hsien Li Peng MD,i Berthold Rzany MD ScM,j Gerhard Sattler MD,k Tunk Tiryaki MD,l Heidi A. Waldorf MD,m and Thierry Besins MDn|BACKGROUND: Communication concepts relating to prevention and early intervention (P&E) within aesthetic medicine are poorly understood and highly underexplored. However, effective communication is a key criterion for successful outcomes. OBJECTIVES: To introduce the framework for P&E communication strategies within a younger population and explore the barriers that may be encountered. METHODS: A literature review on P&E communication strategies in aesthetic medicine and related topics of interest was conducted and used to construct a working framework that may be applied in clinical practice. RESULTS: Examination of existing literature revealed a need for a more structured communication framework for P&E encompassing up-to-date evidence-based learning and educational marketing that is tailored to individual needs and target populations. Message framing—the way in which a message is presented—is an important consideration in the dissemination of information to promote changes in health behaviour. A structured consultation is key to optimising patient engagement and ensures a tailored approach to understanding and catering to the specific needs of each patient. CONCLUSION: This is the first paper to discuss the communication concepts behind P&E within aesthetic medicine and paves the way for further research and focus in this significant field.
J Drugs Dermatol. 2017;16(9):859-864.
Tatjana Pavicic MD,a Konstantin Frank,b Katharina Erlbacher PhD,c Romy Neuner,b Stefan Targosinski MD,d Thilo Schenck MD PhD,b Robert H. Gotkin MD FACS,e and Sebastian Cotofana MD PhDf|BACKGROUND: Precise implantation of soft tissue fillers to treat the signs of aging is crucial for patient safety and the best aesthetic outcome. Injections are performed commonly with either needles or cannulas, but quantitative comparative data on precise implantation are still elusive. METHODS: Ten fresh-frozen cephalic foreheads (9 male, 1 female) were injected with radiopaque material using both needles and cannulas. Needle injection relied on a perpendicular transcutaneous approach, whereas cannulas were moved in the supra-periosteal plane until reaching the same location as the needle. Two-dimensional distribution of the material in the horizontal and in the vertical axes was quantified using fluoroscopic imaging. Additional CT and MR imaging was performed to confirm results. RESULTS: The two-dimensional extent of injected material in the horizontal plane was 25.6 mm±10.5 mm vs 13.5 mm ± 6.5 mm (cannula vs needle; P=0.006) and 3.0 mm ± 0.90 mm vs 3.99 mm ± 0.97 mm (cannula vs needle; P=0.028) in the vertical plane. In 60% of injections using a needle, the implanted material changed its plane; this was not observed when using the cannula (0%; P=0.003). Retrograde backflow, however, was greater with a cannula (90.2%) compared to a needle (33.3%). CONCLUSIONS: If precision in filler injection is defined as the filler material remaining in the plane of intended implantation, then using cannulas resulted in a more precise injection of material as compared to needles. Applications with needles resulted in the distribution of material into more superficial layers, which was not noted for cannulas.
J Drugs Dermatol. 2017;16(9):866-872.
Z. Paul Lorenc MD FACS,a Åke Öhrlund MSc,b and Katarina Edsman PhDc|BACKGROUND: With the number of available dermal fillers increasing, so is the demand for scientifically based comparisons, often with rheological properties in focus. Since analytical results are always influenced by instrument settings, consensus on settings is essential to make comparison of results from different investigators more useful. OBJECTIVE: Preferred measurement settings for rheological analysis of hyaluronic acid (HA) fillers are suggested, and the reasoning behind the choices is presented by demonstrating the effect of different measurement settings on select commercial HA fillers. MATERIALS AND METHODS:Rheological properties of 8 HA fillers were measured in a frequency sweep from 10 to 0.01 Hz at 0.1% strain, using an Anton Paar MCR 301, a PP-25 measuring system with a gap of 1 mm at 25°C. A 30-min period was used for relaxation of the sample between loading and measuring. RESULTS: The data presented here, together with previously published data, demonstrate differences in G’ from 1.6 to 7.4 times for the same product. CONCLUSION:A large part of the differences were concluded to be due to differences in rheometry measurement settings. The confusion from the many parameters involved in rheometry can be avoided by simply using the elastic modulus (G’) to differentiate products.
J Drugs Dermatol. 2017;16(9):876-882.
Susana Raab MS,a Margarita Yatskayer MS,a Stephen Lynch PhD,a Megan Manco MS MPS,b and Christian Oresajo PhDa|BACKGROUND: Hyaluronic acid (HA), the major glycosaminoglycan present in the human skin, is a key contributor to water retention and mechanical support in skin. The level, size, and functionality of cutaneous HA are known to diminish with age. Topical treatments designed to increase the HA content of skin have been met with limited success. The purpose of this study was to evaluate the tolerance and efficacy of a multi-modal facial serum containing HA, Proxylane (C-Xyloside), purple rice extract, and dipotassium glycyrrhizate in addressing HA levels in skin. METHODS: A 12-week, single center, clinical study was conducted on 59 women with mild to moderate photodamage. Clinical grading to assess the efficacy and tolerability was conducted on the face at baseline and at weeks 4, 8, and 12. Bioinstrumentation measurements were taken, including corneometer, tewameter, ultrasound, and standardized digital imaging. A randomized subset of 20 subjects from the study population had 3 mm punch biopsies collected for quantitative RT-PCR analysis from 2 sites on the face at baseline and week 12. Additionally, a 4-week, single center, clinical study was conducted on the photodamaged forearms of 12 subjects. At both baseline and week 4, a 4 mm punch biopsy was obtained from the subjects’ randomized forearms. Biopsy samples were subjected to immunohistochemical staining and analysis of HA content. RESULTS: Statistically-significant improvements in all facial skin attributes (weeks 4, 8, and 12), stratum corneum hydration (week 12), and transepidermal water loss (week 12) were observed. Tolerability was excellent, with no increases in irritation parameters noted. A significant increase of HA content in skin after 4 weeks of treatment was observed. By PCR analysis, there was a significant increase in hyaluronan synthase 2, as well as a significant increase in collagen type 1a1 after 12 weeks of application. CONCLUSION: The findings suggest that this novel topical facial serum is capable of stimulating HA and skin extracellular matrix components, as well as improving skin hydration and skin quality in women with mild to moderate photodamage.
J Drugs Dermatol. 2017;16(9):884-890.
Long-term Comparison of a Large Spot Vacuum Assisted Handpiece vs the Small Spot Size Traditional Handpiece of the 800 nm Diode Laser
Nour J.Youssef MD,a Alain G.Rizk MD,a Omar A. Ibrahimi MD PhD,b,c and Zeina S.Tannous MDa,c|BACKGROUND The 800 nm long-pulsed diode laser machine is safe and effective for permanent hair reduction. Traditionally, most long-pulsed diode lasers used for hair removal had a relatively small spot size. Recently, a long-pulsed diode laser with a large spot size and vacuum assisted suction handpiece was introduced. The treatment parameters of each type of handpiece differ. Short and long-term clinical efficacy, treatment associated pain, and patient satisfaction are important factors to be considered. OBJECTIVE: This study aims to conduct a direct head to head comparison of both handpieces of the 800nm long-pulsed diode laser by evaluating long term hair reduction, treatment associated pain and patient satisfaction. METHODS: Thirteen subjects were enrolled in this prospective, self-controlled, single-center study of axillary laser hair removal. The study involved 4 treatments using a long pulsed diode laser with a large spot size HS handpiece (single pass), HS handpiece (double pass), and a small spot size ET handpiece according to a randomized choice. The treatment sessions were done at 4-8 week intervals with follow up visits taken at 6 and 12 months after the last treatment session. Hair clearance and thickness analysis were assessed using macro hair count photographs taken at baseline visit, at each treatment session visit and at follow up visits. Other factors including pain, treatment duration, and patients’ preference were secondary study endpoints. RESULTS: At 6 months follow up visits after receiving four laser treatments, there was statistically significant hair clearance in the three treatment arms with 66.1 % mean percentage hair reduction with the ET handpiece, 43.6% with the HSS (single pass) and 64.1 % with the HSD (double). However, at one year follow up, the results significantly varied from the 6 months follow up. The mean percentage hair reduction was 57.8% with the ET handpiece treated axillas (n=9), 16.5% with the HSS (single pass) handpiece treated axillas (n=7), and 46.9% with the HSD (double pass) handpiece treated axillas (n=6). Thus, at one year follow up, there was a significant hair reduction that was similar in both the ET and HSD treated axillae (57.8% and 46.9 %), but only minimal hair reduction (16.5%)was observed in the HSS treated axillae. CONCLUSIONS: This is the first study that compared the long-term efficacy of the ET and HS handpieces after four treatment sessions with up to 12 months follow up after the last treatment session. It is also the first study that provided head to head comparison between HS (double pass), HS (single pass), and ET handpiece taking into consideration the end hair reduction result, the time consumed, the pain score experienced, and the overall patient satisfaction. HSD had better hair clearance and patient satisfaction when compared to ET and HSS. The long term follow up results showed that ET was superior to HSS (P less than .05), but was not superior to HSD (P greater than 0.05). However, HSD treated patients had lower pain scores with HSD than with ET. We conclude that ET handpiece is almost as efficacious as HSD handpiece, and the desired end results could be achieved with HDD with better patient satisfaction, less treatment duration and less pain.
J Drugs Dermatol. 2017;16(9):893-898.
Natalia G. Lapatina MD PhDa and Tatiana Pavlenko MD PhDb|BACKGROUND: The collagen-stimulating properties of Radiesse® (calcium hydroxylapatite, CaHA) can be used for skin-tightening procedures by hyper-diluting the product with lidocaine or saline. OBJECTIVE: To evaluate the effectiveness and safety of diluted CaHA for skin tightening in two case series of women with skin laxity in the upper arms or abdomen. METHODS: For each case series, 10 female subjects were enrolled. In the upper arms, CaHA diluted 1:2 with normal saline solution and 2% lidocaine was injected subdermally using a short, linear-threading technique. Skin elasticity was assessed at baseline and Months 1 and 3 using a cutometer. In the abdominal wall, CaHA diluted 1:4 with saline solution was injected subdermally using a linear-threading technique. Subjects underwent pre- and post-treatment (70 days) ultrasound scans to determine dermal thickness around the umbilicus and sides of the abdomen. Subjects and physicians assessed treatment outcomes using the 5-point Global Aesthetic Improvement Scale (GAIS). Adverse events and tolerability were recorded. RESULTS: Cutometry results for upper arm skin showed an increase in skin elasticity from 72 U at baseline to 82 U at Month 3 (P≤0.05). Ultrasound measures of the abdominal wall demonstrated statistically significant increases in dermal thickness after injection of diluted CaHA of 0.7 mm (umbilicus) and 0.4 mm (sides of abdomen). Diluted CaHA resulted in an overall increase in dermal thickness of 26.7% (P≤0.05). In both case series, 90% of subjects and physicians rated treatment outcomes on GAIS as much or very much improved. Treatment was well tolerated. CONCLUSIONS: Diluted CaHA improved skin elasticity and increased dermal thickness in the upper arms and abdomen after only a single treatment. The procedures were well tolerated, and subject and investigator satisfaction with treatment results was very high. Injection of diluted CaHA is an effective procedure for skin tightening in the upper arms and abdomen.
J Drugs Dermatol. 2017;16(9):900-906.
Treatment of Rosacea With Concomitant Use of Topical Ivermectin 1% Cream and Brimonidine 0.33% Gel: A Randomized, Vehicle-controlled Study
Linda Stein Gold MD,a Kim Papp MD PhD FRCPC,b Charles Lynde MD FRCPC,c Edward Lain MD MBA,d Melinda Gooderham MSc MD FRCPC,e Sandra Johnson MD FAAD,f and Nabil Kerrouche MScg|BACKGROUND: There is currently a lack of data on the simultaneous treatment of different features of rosacea. Individually, ivermectin 1% (IVM) cream and brimonidine 0.33% (BR) gel have demonstrated efficacy on inflammatory lesions and persistent erythema, respectively. OBJECTIVE: To evaluate the efficacy, safety, patient satisfaction, and optimal timing of administration of IVM associated with BR (IVM+BR) versus their vehicles in rosacea (investigator global assessment [IGA] ≥3). METHODS: Multicenter, randomized, double-blind study including subjects with rosacea characterized by moderate to severe persistent erythema and inflammatory lesions. The active treatment group included the IVM+BR/12 weeks subgroup (once-daily BR and once-daily IVM for 12 weeks), and the IVM+BR/8 weeks subgroup (once-daily BR vehicle for 4 weeks followed by once-daily BR for the remaining 8 weeks and once-daily IVM for 12 weeks). The vehicle group received once-daily BR vehicle and once-daily IVM vehicle for 12 weeks. RESULTS: The association showed superior efficacy (IGA success [clear/almost clear]) for erythema and inflammatory lesions in the total active group (combined active subgroups) compared to vehicle (55.8% vs. 36.8%, P=0.007) at week 12. The success rate increased from 32.7% to 61.2% at hour 0 and hour 3, respectively, in the IVM+BR/12 weeks subgroup, and from 28.3% to 50% in the IVM+BR/8 weeks subgroup. Reductions in erythema and inflammatory lesion counts confirmed the additive effect of BR to IVM treatment. Subjects reported greater improvement in the active subgroups than in the vehicle group, and similar rates for facial appearance satisfaction after the first 4 weeks of treatment in both active subgroups. All groups showed similar tolerability profiles. CONCLUSION: Concomitant administration of IVM cream with BR gel demonstrated good efficacy and safety, endorsing the comprehensive approach to this complex disease. Early introduction of BR, along with a complete daily skin care regimen may accelerate treatment success without impairing tolerability.
J Drugs Dermatol. 2017;16(9):909-916.
Lauren K. Hoffman BSa and Leon Kircik MDb|BACKGROUND: Atopic dermatitis (AD) is a chronic, relapsing, inflammatory skin disorder. One of the most disturbing symptoms of AD is pruritus. The first line treatment for AD is topical corticosteroids, topical immunomodulators, topical barrier creams, oral antihistamines, and systemic treatments. Desoximetasone 0.25% spray is a superpotent topical corticosteroid delivered in a novel way and it may be a suitable option for the treatment of pruritus in adult atopic dermatitis patients. STUDY DESIGN: A single-center, open labeled pilot study was conducted to investigate the efficacy and safety of desoximetasone 0.25% spray for pruritus in adult atopic dermatitis patients. RESULTS: Twice daily application of desoximetasone 0.25% spray to affected areas resulted in a significant reduction in all outcomes (IGA, pruritus, VAS assessment of pruritus) within 1 week of initiation of treatment. The reductions exhibited were sustained throughout the study period of 4 weeks. Significant improvements in quality of life, as measured by the DLQI, were observed. No adverse events were reported. CONCLUSION: Desoximetasone 0.25% spray is effective for treating pruritic symptoms of AD. Given its efficacy and convenience as a spray, desoximetasone 0.25% spray should continue to be evaluated as a treatment for AD in larger trials.
J Drugs Dermatol. 2017;16(9):919-922.
Successful Treatment of Keloid With Fractionated Carbon Dioxide (CO2) Laser and Laser-Assisted Drug Delivery of Triamcinolone Acetonide Ointment in an African-American Man
Ekaterina Kraeva MD,a,b Derek Ho MD,a,b and Jared Jagdeo MD MSa,b,c|Keloids are fibrous growths that occur as a result of abnormal response to dermal injury. Keloids are cosmetically disfiguring and may impair function, often resulting in decreased patient quality-of-life. Treatment of keloids remains challenging, and rate of recurrence is high. We present a case of a 39-year-old African-American man (Fitzpatrick VI) with a 10-year history of keloid, who was successfully treated with eight sessions of fractionated carbon dioxide (CO2) laser immediately followed by laser-assisted drug delivery (LADD) of topical triamcinolone acetonide (TAC) ointment and review the medical literature on fractionated CO2 laser treatment of keloids. To the best of our knowledge, this is the first report of successful treatment of a keloid using combination therapy of fractionated CO2 laser and LADD with topical TAC ointment in an African-American man (Fitzpatrick VI) with excellent cosmetic results sustained at 22 months post-treatment. We believe that this combination treatment modality may be safe and efficacious for keloids in skin of color (Fitzpatrick IV-VI) and other patients. This case highlights the ability of laser surgeons to safely use fractionated CO2 lasers in patients of all skin colors.
J Drugs Dermatol. 2017;16(9):925-927.
Suzan Obagi MD and Kseniya Golubets MD MHS|Onabotulinumtoxin A (Botox) can be a safe and successful off-label treatment of vertical platysma bands of various severities. Due to risk of the botulinum toxin diffusing to the underlying anatomic structures such as the deglutition muscles, the larynx, and the neck flexors, a maximal dose of 100 units has been suggested and there have been no known reports of untoward effects with doses less than 60 units. We present a case of mild to moderate dysphagia in a patient after very low doses of Abobutulinumtoxin (60 units, equivalent to 20 units of Onabotulinumtoxin using a 3:1 conversion ratio). We speculate that the adverse effects noted may be due to several possibilities, such as diffusion, injection technique, or intravascular injection. Thus, although botulinum toxin-A is generally considered a safe off-label treatment for vertical platysma bands, readers should still be aware of the possible side-effects even with low dose use, as supported by our case report of mild to moderate dysphagia with relatively conservative doses of Abobotulinumtoxin A.
J Drugs Dermatol. 2017;16(9):929-930.
Kian Karimi MD FACS and Alexandra Reivitis BA|Traditional rejuvenation techniques include chemical peels, rhytidectomy of the skin, laser resurfacing, injection of dermal fillers and neurotoxins, and invasive surgical procedures. Patients with brow ptosis, jowl formation, and deepening nasolabial folds currently seek antiaging procedures with no incisions and minimal downtime such as thread-lifting with barbed sutures. The present report describes a case in which polydioxanone threads were used to lift the lower third of a patient’s face. Fillers were used to supplement the results achieved by the thread lift because often, when tissue has been lifted, volume deficits are revealed, which can be corrected with dermal fillers. The procedure was performed in less than 30 minutes and was well tolerated. Mild swelling at the insertion points and general treatment area resolved within 7 days without intervention. Bruising was not observed. The patient showed remarkable improvement 7 months after the procedure.
J Drugs Dermatol. 2017;16(9):932-934.
NEWS, VIEWS, AND REVIEWS: A Tool for My Laser Practice I Simply Can’t Do Without: Shining a Light on My Favorite Light (Source)
Eric F. Bernstein MD MSE|With laser surgery, what you see is what you get. Visualizing the target for treatment, be it a port-wine stain, a cluster of spider veins, a tattoo or freckles, or simply photodamaged skin requires seeing through surface reflections, dry skin, and often quite dark laser goggles. The tool that has been indispensable to me in my practice is the Syris v900L polarizing and magnifying headlamp. This indispensable tool makes laser treatment more precise, effective, and easier by truly shining a light on the subject of a laser treatment. Future uses of this dynamic, yet simple invention, should be found in all of dermatology and beyond, anywhere that seeing what you are looking at more clearly is important.
J Drugs Dermatol. 2017;16(9):939-944.