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Hypopigmentation
Hypopigmentation or depigmentation of the skin is very challenging to treat. The loss of melanin in the skin is often a frustrating problem, resulting from acne, burn scars, vitiligo, topically applied chemicals, or cryotherapy. To date, there is no universally accepted treatment that restores skin pigmentation. In our clinic, the induction of trauma to the skin via a series of microneedling or subcision treatments has shown promise in increasing the pigmentation of skin with localized hypo- or depigmented patches.
to improve the appearance of fine lines, acne scars, photoaging, stretch marks, enlarged pores, and other cosmetic issues characterized by loss of collagen or altered collagen remodeling. The skin-needling technique involves fine sterile needles 0.1 mm–2.5 mm in length that repeatedly pierce the stratum corneum producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. Similar to microneedling, subcision uses repeat trauma to the dermis and subcutis through the insertion and repeat movement of a needle.
In our practice, patients presenting with hypopigmentation of the skin from a variety of causes have been treated with a series of five subcision or microneedling procedures, resulting in rapid repigmentation of the skin with minimal to no side effects. Trauma to the skin causes regenerative mechanisms and wound healing. The release of cytokines that induce neoangiogenesis, neocollagenesis, and the deposition of hemosiderin from dermal bleeding induce the activation of melanocytes and stimulate skin pigmentation.
Subcision and microneedling are safe, effective, in-office procedures with vast indications that now can be applied to depigmented and hypopigmented skin. Patients have little to no downtime and results are permanent.
Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Dermatol Surg. 1995 Jun;21(6):543-9.
Aesthet Plast Surg. 1997 Jan-Feb;21(1):48-51.
Oral Maxillofac Surg Clin North Am. 2005 Feb;17(1):51-63.
Plast Reconstr Surg. 2008 Apr;121(4):1421-9.
Clin Dermatol. 2008 Mar-Apr;26(2):192-9.Plast Reconstr Surg. 2008 Nov;122(5):1553-63.
J Dermatolog Treat. 2012 Apr;23(2):144-52.
J Cutan Aesthet Surg. 2009 Jan;2(1):26-30.
J Cutan Aesthet Surg. 2009 Jul;2(2):110-1.
J Cosmet Dermatol. 2014 Sep;13(3):180-7.J Am Acad Dermatol. 2016 Nov;75(5):e195-e197.
Hypopigmentation or depigmentation of the skin is very challenging to treat. The loss of melanin in the skin is often a frustrating problem, resulting from acne, burn scars, vitiligo, topically applied chemicals, or cryotherapy. To date, there is no universally accepted treatment that restores skin pigmentation. In our clinic, the induction of trauma to the skin via a series of microneedling or subcision treatments has shown promise in increasing the pigmentation of skin with localized hypo- or depigmented patches.
to improve the appearance of fine lines, acne scars, photoaging, stretch marks, enlarged pores, and other cosmetic issues characterized by loss of collagen or altered collagen remodeling. The skin-needling technique involves fine sterile needles 0.1 mm–2.5 mm in length that repeatedly pierce the stratum corneum producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. Similar to microneedling, subcision uses repeat trauma to the dermis and subcutis through the insertion and repeat movement of a needle.
In our practice, patients presenting with hypopigmentation of the skin from a variety of causes have been treated with a series of five subcision or microneedling procedures, resulting in rapid repigmentation of the skin with minimal to no side effects. Trauma to the skin causes regenerative mechanisms and wound healing. The release of cytokines that induce neoangiogenesis, neocollagenesis, and the deposition of hemosiderin from dermal bleeding induce the activation of melanocytes and stimulate skin pigmentation.
Subcision and microneedling are safe, effective, in-office procedures with vast indications that now can be applied to depigmented and hypopigmented skin. Patients have little to no downtime and results are permanent.
Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Dermatol Surg. 1995 Jun;21(6):543-9.
Aesthet Plast Surg. 1997 Jan-Feb;21(1):48-51.
Oral Maxillofac Surg Clin North Am. 2005 Feb;17(1):51-63.
Plast Reconstr Surg. 2008 Apr;121(4):1421-9.
Clin Dermatol. 2008 Mar-Apr;26(2):192-9.Plast Reconstr Surg. 2008 Nov;122(5):1553-63.
J Dermatolog Treat. 2012 Apr;23(2):144-52.
J Cutan Aesthet Surg. 2009 Jan;2(1):26-30.
J Cutan Aesthet Surg. 2009 Jul;2(2):110-1.
J Cosmet Dermatol. 2014 Sep;13(3):180-7.J Am Acad Dermatol. 2016 Nov;75(5):e195-e197.
Hypopigmentation or depigmentation of the skin is very challenging to treat. The loss of melanin in the skin is often a frustrating problem, resulting from acne, burn scars, vitiligo, topically applied chemicals, or cryotherapy. To date, there is no universally accepted treatment that restores skin pigmentation. In our clinic, the induction of trauma to the skin via a series of microneedling or subcision treatments has shown promise in increasing the pigmentation of skin with localized hypo- or depigmented patches.
to improve the appearance of fine lines, acne scars, photoaging, stretch marks, enlarged pores, and other cosmetic issues characterized by loss of collagen or altered collagen remodeling. The skin-needling technique involves fine sterile needles 0.1 mm–2.5 mm in length that repeatedly pierce the stratum corneum producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. Similar to microneedling, subcision uses repeat trauma to the dermis and subcutis through the insertion and repeat movement of a needle.
In our practice, patients presenting with hypopigmentation of the skin from a variety of causes have been treated with a series of five subcision or microneedling procedures, resulting in rapid repigmentation of the skin with minimal to no side effects. Trauma to the skin causes regenerative mechanisms and wound healing. The release of cytokines that induce neoangiogenesis, neocollagenesis, and the deposition of hemosiderin from dermal bleeding induce the activation of melanocytes and stimulate skin pigmentation.
Subcision and microneedling are safe, effective, in-office procedures with vast indications that now can be applied to depigmented and hypopigmented skin. Patients have little to no downtime and results are permanent.
Dr. Talakoub and Dr. Wesley are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Dermatol Surg. 1995 Jun;21(6):543-9.
Aesthet Plast Surg. 1997 Jan-Feb;21(1):48-51.
Oral Maxillofac Surg Clin North Am. 2005 Feb;17(1):51-63.
Plast Reconstr Surg. 2008 Apr;121(4):1421-9.
Clin Dermatol. 2008 Mar-Apr;26(2):192-9.Plast Reconstr Surg. 2008 Nov;122(5):1553-63.
J Dermatolog Treat. 2012 Apr;23(2):144-52.
J Cutan Aesthet Surg. 2009 Jan;2(1):26-30.
J Cutan Aesthet Surg. 2009 Jul;2(2):110-1.
J Cosmet Dermatol. 2014 Sep;13(3):180-7.J Am Acad Dermatol. 2016 Nov;75(5):e195-e197.
Whole body cryotherapy
.
WBC has been purported to manage pain, reduce inflammation, and speed up recovery after injury, as well as relieve sore muscles after exercise, aid in weight loss, and improve mood. There have also been claims that it can treat acne, eczema, and psoriasis – even multiple sclerosis, fibromyalgia, and rheumatoid arthritis. It has been used as a beauty aid to reduce pore size and reduce wrinkles. Its popularity has exploded as centers are advertised on discount sites such as Groupon and Living Social, and it is now available as classes in the popular exercise app ClassPass as “Whole Body Cryotherapy” or a “CryoBeauty Facial.”
Despite these claims and popularity, research studies have yet to prove that WBC can deliver any of these benefits. The American Academy of Dermatology has released a statement for consumers that does not support its use. Because of the lack of research, WBC has not been cleared by the Food and Drug Administration for treating any medical indication.
Its popularity has to stem from somewhere. In many cultures, cold therapy has been used for health benefits for centuries. For example, Turkish, Russian, Finnish, Roman, and Chinese spas offer cold baths at 50 degrees Fahrenheit after heat therapy (saunas, baths) as a form of hydrotherapy to alter circulation for health benefits, with the goal of releasing toxins with heat, then closing pores and bringing the circulation back to the body’s core with cold therapy. Cold ice baths and ice packs are used by athletes routinely after games, practices, and injuries to reduce inflammation. How is WBC different?
With WBC, a person who is nearly nude enters a cold chamber of minus 200 degrees Fahrenheit, in sessions that typically last 2-4 minutes.
While the majority of those who engage in WBC have not had complications, the AAD statement refers to a Finnish study that found that 16% of individuals exposed to WBC had mild frostbite. In 2011, U.S. sprinter and Olympic gold medalist Justin Gatlin developed frostbite on both feet after a WBC session. Additional WBC-related complications that have been reported include a frozen limb (a frozen arm in a woman in Dallas in 2013, after a 3-minute session, manifesting as painful swelling, blisters, and third-degree burns – a more severe type of frostbite), and cold panniculitis (JAAD Case Rep. 2018;4:344-5). Others include eye injuries, temporary loss of memory, and even death due to suffocation, reported in 2015, of a staff member at a cryotherapy center outside of Las Vegas who went into a tank alone after hours when no one else was around.
Cryotherapy, when delivered to specific areas of the skin by a dermatologist, is a useful low-risk treatment. Postinflammatory pigment alteration can occur, but there has been great success in using the treatment locally for warts, actinic keratoses, and other benign skin growths, when it is done done by trained professionals. Granted, while localized cryotherapy to treat a skin growth is not the same as whole body cryotherapy, the same types of complication risks should be considered, including postinflammatory pigment alteration, particularly in skin of color, as cryotherapy can be toxic to melanocytes.
Before it is completely discounted, if it makes the person feel good or better, perhaps if the patient and practitioner are aware of the risks and how to identify and manage them, cold therapy could be useful. I once had a patient who described great relief with WBC after a Fraxel laser treatment, when her face felt like it was “on fire” despite refrigerated topical Biafine, cold air, and ice packs. As with most treatments, if someone feels better, they often look better.
While medical or aesthetic benefits of WBC have not been proved and WBC has definite risks, if the procedure is done in an appropriate and responsible way, perhaps the benefit could outweigh the informed risks for some patients. Claims should not be advertised until they are proven, so that patients are not misinformed. The same is true of chemical peels, microneedling, hyperbaric oxygen, and vitamin drips, which are provided over the counter in nonmedical settings for health and beauty uses. Medical history should be taken into account with WBC by the facility and the practitioner, including history of blood clots, smoking, vasculitis, Raynaud’s disease, autoimmune conditions, neuropathy, and prior history of frostbite. Perhaps these should be contraindications to WBC and mechanisms should be in place to manage complications should they occur. Better regulation of WBC is needed so that the procedure can be done effectively and safely.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
.
WBC has been purported to manage pain, reduce inflammation, and speed up recovery after injury, as well as relieve sore muscles after exercise, aid in weight loss, and improve mood. There have also been claims that it can treat acne, eczema, and psoriasis – even multiple sclerosis, fibromyalgia, and rheumatoid arthritis. It has been used as a beauty aid to reduce pore size and reduce wrinkles. Its popularity has exploded as centers are advertised on discount sites such as Groupon and Living Social, and it is now available as classes in the popular exercise app ClassPass as “Whole Body Cryotherapy” or a “CryoBeauty Facial.”
Despite these claims and popularity, research studies have yet to prove that WBC can deliver any of these benefits. The American Academy of Dermatology has released a statement for consumers that does not support its use. Because of the lack of research, WBC has not been cleared by the Food and Drug Administration for treating any medical indication.
Its popularity has to stem from somewhere. In many cultures, cold therapy has been used for health benefits for centuries. For example, Turkish, Russian, Finnish, Roman, and Chinese spas offer cold baths at 50 degrees Fahrenheit after heat therapy (saunas, baths) as a form of hydrotherapy to alter circulation for health benefits, with the goal of releasing toxins with heat, then closing pores and bringing the circulation back to the body’s core with cold therapy. Cold ice baths and ice packs are used by athletes routinely after games, practices, and injuries to reduce inflammation. How is WBC different?
With WBC, a person who is nearly nude enters a cold chamber of minus 200 degrees Fahrenheit, in sessions that typically last 2-4 minutes.
While the majority of those who engage in WBC have not had complications, the AAD statement refers to a Finnish study that found that 16% of individuals exposed to WBC had mild frostbite. In 2011, U.S. sprinter and Olympic gold medalist Justin Gatlin developed frostbite on both feet after a WBC session. Additional WBC-related complications that have been reported include a frozen limb (a frozen arm in a woman in Dallas in 2013, after a 3-minute session, manifesting as painful swelling, blisters, and third-degree burns – a more severe type of frostbite), and cold panniculitis (JAAD Case Rep. 2018;4:344-5). Others include eye injuries, temporary loss of memory, and even death due to suffocation, reported in 2015, of a staff member at a cryotherapy center outside of Las Vegas who went into a tank alone after hours when no one else was around.
Cryotherapy, when delivered to specific areas of the skin by a dermatologist, is a useful low-risk treatment. Postinflammatory pigment alteration can occur, but there has been great success in using the treatment locally for warts, actinic keratoses, and other benign skin growths, when it is done done by trained professionals. Granted, while localized cryotherapy to treat a skin growth is not the same as whole body cryotherapy, the same types of complication risks should be considered, including postinflammatory pigment alteration, particularly in skin of color, as cryotherapy can be toxic to melanocytes.
Before it is completely discounted, if it makes the person feel good or better, perhaps if the patient and practitioner are aware of the risks and how to identify and manage them, cold therapy could be useful. I once had a patient who described great relief with WBC after a Fraxel laser treatment, when her face felt like it was “on fire” despite refrigerated topical Biafine, cold air, and ice packs. As with most treatments, if someone feels better, they often look better.
While medical or aesthetic benefits of WBC have not been proved and WBC has definite risks, if the procedure is done in an appropriate and responsible way, perhaps the benefit could outweigh the informed risks for some patients. Claims should not be advertised until they are proven, so that patients are not misinformed. The same is true of chemical peels, microneedling, hyperbaric oxygen, and vitamin drips, which are provided over the counter in nonmedical settings for health and beauty uses. Medical history should be taken into account with WBC by the facility and the practitioner, including history of blood clots, smoking, vasculitis, Raynaud’s disease, autoimmune conditions, neuropathy, and prior history of frostbite. Perhaps these should be contraindications to WBC and mechanisms should be in place to manage complications should they occur. Better regulation of WBC is needed so that the procedure can be done effectively and safely.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
.
WBC has been purported to manage pain, reduce inflammation, and speed up recovery after injury, as well as relieve sore muscles after exercise, aid in weight loss, and improve mood. There have also been claims that it can treat acne, eczema, and psoriasis – even multiple sclerosis, fibromyalgia, and rheumatoid arthritis. It has been used as a beauty aid to reduce pore size and reduce wrinkles. Its popularity has exploded as centers are advertised on discount sites such as Groupon and Living Social, and it is now available as classes in the popular exercise app ClassPass as “Whole Body Cryotherapy” or a “CryoBeauty Facial.”
Despite these claims and popularity, research studies have yet to prove that WBC can deliver any of these benefits. The American Academy of Dermatology has released a statement for consumers that does not support its use. Because of the lack of research, WBC has not been cleared by the Food and Drug Administration for treating any medical indication.
Its popularity has to stem from somewhere. In many cultures, cold therapy has been used for health benefits for centuries. For example, Turkish, Russian, Finnish, Roman, and Chinese spas offer cold baths at 50 degrees Fahrenheit after heat therapy (saunas, baths) as a form of hydrotherapy to alter circulation for health benefits, with the goal of releasing toxins with heat, then closing pores and bringing the circulation back to the body’s core with cold therapy. Cold ice baths and ice packs are used by athletes routinely after games, practices, and injuries to reduce inflammation. How is WBC different?
With WBC, a person who is nearly nude enters a cold chamber of minus 200 degrees Fahrenheit, in sessions that typically last 2-4 minutes.
While the majority of those who engage in WBC have not had complications, the AAD statement refers to a Finnish study that found that 16% of individuals exposed to WBC had mild frostbite. In 2011, U.S. sprinter and Olympic gold medalist Justin Gatlin developed frostbite on both feet after a WBC session. Additional WBC-related complications that have been reported include a frozen limb (a frozen arm in a woman in Dallas in 2013, after a 3-minute session, manifesting as painful swelling, blisters, and third-degree burns – a more severe type of frostbite), and cold panniculitis (JAAD Case Rep. 2018;4:344-5). Others include eye injuries, temporary loss of memory, and even death due to suffocation, reported in 2015, of a staff member at a cryotherapy center outside of Las Vegas who went into a tank alone after hours when no one else was around.
Cryotherapy, when delivered to specific areas of the skin by a dermatologist, is a useful low-risk treatment. Postinflammatory pigment alteration can occur, but there has been great success in using the treatment locally for warts, actinic keratoses, and other benign skin growths, when it is done done by trained professionals. Granted, while localized cryotherapy to treat a skin growth is not the same as whole body cryotherapy, the same types of complication risks should be considered, including postinflammatory pigment alteration, particularly in skin of color, as cryotherapy can be toxic to melanocytes.
Before it is completely discounted, if it makes the person feel good or better, perhaps if the patient and practitioner are aware of the risks and how to identify and manage them, cold therapy could be useful. I once had a patient who described great relief with WBC after a Fraxel laser treatment, when her face felt like it was “on fire” despite refrigerated topical Biafine, cold air, and ice packs. As with most treatments, if someone feels better, they often look better.
While medical or aesthetic benefits of WBC have not been proved and WBC has definite risks, if the procedure is done in an appropriate and responsible way, perhaps the benefit could outweigh the informed risks for some patients. Claims should not be advertised until they are proven, so that patients are not misinformed. The same is true of chemical peels, microneedling, hyperbaric oxygen, and vitamin drips, which are provided over the counter in nonmedical settings for health and beauty uses. Medical history should be taken into account with WBC by the facility and the practitioner, including history of blood clots, smoking, vasculitis, Raynaud’s disease, autoimmune conditions, neuropathy, and prior history of frostbite. Perhaps these should be contraindications to WBC and mechanisms should be in place to manage complications should they occur. Better regulation of WBC is needed so that the procedure can be done effectively and safely.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
Treating the effects of bruxism with botulinum toxin
Bruxism is grinding and clenching of the teeth with unconscious contractions of the temporal and masseter muscles while awake or during sleep. Bruxism occurs in 8%-16% of the population and is often an underdiagnosed condition that not only leads to dental problems but also to pain in the teeth, jaw, temporomandibular joint, and neck; headaches; and potentially, to tooth loss.
Although the pathogenesis of bruxism remains unclear, multiple factors, such as physical or psychological stress, malocclusion, sleep disorders and medication side effects, can cause bruxism. Treatment can be difficult given psychogenic and neurogenic components, and bruxism can be resistant to medical and behavioral therapy. There are various treatment options for bruxism, including oral splints; medications, such as muscle relaxants; antidepressants; and botulinum toxin. Multiple studies have shown that botulinum toxin injections into the masseter and temporalis muscles result in relaxation of the muscles and improvement of bruxism and the pain associated with chronic clenching and grinding.
In a recent study by Al-Wayli, 50 subjects who reported nocturnal bruxism were randomized to receive botulinum toxin versus conventional treatment (pharmacotherapy or oral splints). After 3 weeks, 2 months, 6 months, and 1 year, patients who received botulinum toxin had significantly less pain after only one treatment than did the traditional treatment group. Similarly, in a study by Lee et al., subjects randomized to receive botulinum toxin versus a placebo saline injections showed not only decreased pain but also decreased bruxism seen with nocturnal electromyography.
In our clinic, Botulinum toxin when injected into the temporalis and masseter muscles also helps with tension headaches and migraines related to clenching of the jaw. Albeit effective, the dose of botulinum toxin used in the aforementioned studies ranged between 25 U and 40 U of botulinum toxin and were lower than what we have found to be effective. Our patients receive 50 U botulinum toxin in each masseter muscle (100 U total). In a small minority of our patients, the temporalis muscle also needed 15-20 U per side as well. Clinical improvement starts within 3-5 days, and patients can expect to have relaxation of the muscle and decreased pain for 6 months. Side effects include mild swelling and bruising. Rarely, if the injection is not performed properly, the risorius muscle may be paralyzed, leading to an asymmetric smile. In addition, if the botulinum toxin is underdosed, the pain may not completely subside and the patient may report some symptoms returning within a couple of weeks of the initial treatment. Most patients also report thinning of the face and jaw, which is a much anticipated and appreciated result. Masseter hypertrophy with and without bruxism is treated similarly with botulinum toxin to sculpt the lower face.
Bruxism is a growing problem leading to facial pain, headaches, migraines, and significant dental pathology. Traditional treatments have been ineffective at treating the pain and masseter hypertrophy associated with chronic grinding and clenching. Botulinum toxin is a safe, effective, treatment with little downtime or side effects for treating both the neurogenic and muscular components of bruxism.
Dr. Lily Talakoub and Dr. Naissan Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Al-Wayli H. J Clin Exp Dent. 2017 Jan 1;9(1):e112-e117.
Asutay F et al. Pain Res Manag. 2017;2017:6264146. doi: 10.1155/2017/6264146.
Lee SJ et al. Am J Phys Med Rehabil. 2010 Jan;89(1):16-23.
Santamato A et al. J Chiropr Med. 2010 Sep;9(3):132-7.
Shetty S et al. J Indian Prosthodont Soc. 2010 Sep;10(3):141-8.
Tan EK et al. J Am Dent Assoc. 2000 Feb;131(2):211-6.
Bruxism is grinding and clenching of the teeth with unconscious contractions of the temporal and masseter muscles while awake or during sleep. Bruxism occurs in 8%-16% of the population and is often an underdiagnosed condition that not only leads to dental problems but also to pain in the teeth, jaw, temporomandibular joint, and neck; headaches; and potentially, to tooth loss.
Although the pathogenesis of bruxism remains unclear, multiple factors, such as physical or psychological stress, malocclusion, sleep disorders and medication side effects, can cause bruxism. Treatment can be difficult given psychogenic and neurogenic components, and bruxism can be resistant to medical and behavioral therapy. There are various treatment options for bruxism, including oral splints; medications, such as muscle relaxants; antidepressants; and botulinum toxin. Multiple studies have shown that botulinum toxin injections into the masseter and temporalis muscles result in relaxation of the muscles and improvement of bruxism and the pain associated with chronic clenching and grinding.
In a recent study by Al-Wayli, 50 subjects who reported nocturnal bruxism were randomized to receive botulinum toxin versus conventional treatment (pharmacotherapy or oral splints). After 3 weeks, 2 months, 6 months, and 1 year, patients who received botulinum toxin had significantly less pain after only one treatment than did the traditional treatment group. Similarly, in a study by Lee et al., subjects randomized to receive botulinum toxin versus a placebo saline injections showed not only decreased pain but also decreased bruxism seen with nocturnal electromyography.
In our clinic, Botulinum toxin when injected into the temporalis and masseter muscles also helps with tension headaches and migraines related to clenching of the jaw. Albeit effective, the dose of botulinum toxin used in the aforementioned studies ranged between 25 U and 40 U of botulinum toxin and were lower than what we have found to be effective. Our patients receive 50 U botulinum toxin in each masseter muscle (100 U total). In a small minority of our patients, the temporalis muscle also needed 15-20 U per side as well. Clinical improvement starts within 3-5 days, and patients can expect to have relaxation of the muscle and decreased pain for 6 months. Side effects include mild swelling and bruising. Rarely, if the injection is not performed properly, the risorius muscle may be paralyzed, leading to an asymmetric smile. In addition, if the botulinum toxin is underdosed, the pain may not completely subside and the patient may report some symptoms returning within a couple of weeks of the initial treatment. Most patients also report thinning of the face and jaw, which is a much anticipated and appreciated result. Masseter hypertrophy with and without bruxism is treated similarly with botulinum toxin to sculpt the lower face.
Bruxism is a growing problem leading to facial pain, headaches, migraines, and significant dental pathology. Traditional treatments have been ineffective at treating the pain and masseter hypertrophy associated with chronic grinding and clenching. Botulinum toxin is a safe, effective, treatment with little downtime or side effects for treating both the neurogenic and muscular components of bruxism.
Dr. Lily Talakoub and Dr. Naissan Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Al-Wayli H. J Clin Exp Dent. 2017 Jan 1;9(1):e112-e117.
Asutay F et al. Pain Res Manag. 2017;2017:6264146. doi: 10.1155/2017/6264146.
Lee SJ et al. Am J Phys Med Rehabil. 2010 Jan;89(1):16-23.
Santamato A et al. J Chiropr Med. 2010 Sep;9(3):132-7.
Shetty S et al. J Indian Prosthodont Soc. 2010 Sep;10(3):141-8.
Tan EK et al. J Am Dent Assoc. 2000 Feb;131(2):211-6.
Bruxism is grinding and clenching of the teeth with unconscious contractions of the temporal and masseter muscles while awake or during sleep. Bruxism occurs in 8%-16% of the population and is often an underdiagnosed condition that not only leads to dental problems but also to pain in the teeth, jaw, temporomandibular joint, and neck; headaches; and potentially, to tooth loss.
Although the pathogenesis of bruxism remains unclear, multiple factors, such as physical or psychological stress, malocclusion, sleep disorders and medication side effects, can cause bruxism. Treatment can be difficult given psychogenic and neurogenic components, and bruxism can be resistant to medical and behavioral therapy. There are various treatment options for bruxism, including oral splints; medications, such as muscle relaxants; antidepressants; and botulinum toxin. Multiple studies have shown that botulinum toxin injections into the masseter and temporalis muscles result in relaxation of the muscles and improvement of bruxism and the pain associated with chronic clenching and grinding.
In a recent study by Al-Wayli, 50 subjects who reported nocturnal bruxism were randomized to receive botulinum toxin versus conventional treatment (pharmacotherapy or oral splints). After 3 weeks, 2 months, 6 months, and 1 year, patients who received botulinum toxin had significantly less pain after only one treatment than did the traditional treatment group. Similarly, in a study by Lee et al., subjects randomized to receive botulinum toxin versus a placebo saline injections showed not only decreased pain but also decreased bruxism seen with nocturnal electromyography.
In our clinic, Botulinum toxin when injected into the temporalis and masseter muscles also helps with tension headaches and migraines related to clenching of the jaw. Albeit effective, the dose of botulinum toxin used in the aforementioned studies ranged between 25 U and 40 U of botulinum toxin and were lower than what we have found to be effective. Our patients receive 50 U botulinum toxin in each masseter muscle (100 U total). In a small minority of our patients, the temporalis muscle also needed 15-20 U per side as well. Clinical improvement starts within 3-5 days, and patients can expect to have relaxation of the muscle and decreased pain for 6 months. Side effects include mild swelling and bruising. Rarely, if the injection is not performed properly, the risorius muscle may be paralyzed, leading to an asymmetric smile. In addition, if the botulinum toxin is underdosed, the pain may not completely subside and the patient may report some symptoms returning within a couple of weeks of the initial treatment. Most patients also report thinning of the face and jaw, which is a much anticipated and appreciated result. Masseter hypertrophy with and without bruxism is treated similarly with botulinum toxin to sculpt the lower face.
Bruxism is a growing problem leading to facial pain, headaches, migraines, and significant dental pathology. Traditional treatments have been ineffective at treating the pain and masseter hypertrophy associated with chronic grinding and clenching. Botulinum toxin is a safe, effective, treatment with little downtime or side effects for treating both the neurogenic and muscular components of bruxism.
Dr. Lily Talakoub and Dr. Naissan Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Al-Wayli H. J Clin Exp Dent. 2017 Jan 1;9(1):e112-e117.
Asutay F et al. Pain Res Manag. 2017;2017:6264146. doi: 10.1155/2017/6264146.
Lee SJ et al. Am J Phys Med Rehabil. 2010 Jan;89(1):16-23.
Santamato A et al. J Chiropr Med. 2010 Sep;9(3):132-7.
Shetty S et al. J Indian Prosthodont Soc. 2010 Sep;10(3):141-8.
Tan EK et al. J Am Dent Assoc. 2000 Feb;131(2):211-6.
Fish pedicures
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
A letter published in JAMA Dermatology describes an otherwise healthy woman in her 20s who experienced nail abnormalities some months after having a fish pedicure. Onychomadesis, or transverse splitting of the nail plate, occurs when the nail matrix has arrested in producing the nail plate. It can be thought of as more severe form of Beau’s lines, in which the nail itself actually breaks and separates from the proximal nail plate and eventually sheds.
Fish pedicures have a long-standing history in Mediterranean and Middle Eastern cultures for aiding such skin conditions as psoriasis and helping to remove scaly skin. The Garra rufa fish are nonmigratory freshwater fish native to the Persian Gulf and Eastern Mediterranean. Suction allows them to attach to rocks and eat plankton. These “doctor fish,” as they are nicknamed, when placed in a warm bath of 25°C to 30°C, will also eat human skin when starved of their natural food source. As the JAMA Dermatology letter mentions, this was demonstrated in a study in Kangal, Turkey, where Garra rufa fish were used to improve psoriasis by feeding on psoriasis plaques but not normal skin. After 3 weeks of therapy with Garra rufa in 67 patients, there was a 72% reduction in the Psoriasis Area and Severity Index (PASI) score from baseline (Evid Based Complement Alternat Med. 2006 Dec;3[4]:483-8).
Popular in the United States and Europe about a decade ago, fish pedicures have now been banned in 10 U.S. states and in some parts of Europe. While the trend in the United States has waned, fish pedicures have recently become more popular in vacation destinations, such as the Caribbean. The inherent concern of fish pedicures is risk of infection as the same fish are used successively and cannot be adequately sanitized between people.
Two cases of staphylococcus infections and one of Mycobacterium marinum have been reported after fish pedicures. Whether these infections were caused by the fish or the water source, however, remains to be determined. If the fish were transmitting infections, it seems that more infections would likely have been reported, considering the widespread popularity in the past. I, like Antonella Tosti, MD, who commented in a CNN report on the JAMA Dermatology case, also doubt that the fish pedicure alone caused onychomadesis in this woman. In order for onychomadesis to occur, there would have had to have been significant trauma to all 10 nails at the matrix. Would the fish been able to have caused the same amount of trauma to all 10 nails in one setting? While it is possible, I believe a more likely explanation would be an alternate endogenous or exogenous source.
Traditional medicine has been used to enhance beauty and cure ailments for thousands of years before the advent of modern medicine as demonstrated by the Kangal study. Before discounting fish pedicures completely, perhaps some thought should also be given to how this practice affects wildlife and the fish. The CNN report refers to a 2011 investigation by the U.K.’s Fish Health Inspectorate, which “found a bacterial outbreak among thousands of these fish, which had been transported from Indonesia to the United Kingdom pedicure spas. Fish were found with bulging eyes, many hemorrhaging around the gills and mouth. The culprit was found to be a streptococcal bacteria, a strain that is associated with fish like tilapia, according to David Verner-Jeffreys, a senior microbiologist at the Centre for Environment, Fisheries and Aquaculture Science in the U.K.”
Whether or not these fish would pose any risk to humans is unknown, but certainly, this practice adversely affects the welfare of the fish and their environment. The overharvesting of these fish has led the Turkish government to introduce legal protections for the country’s Garra rufa in an attempt to combat overfishing and exploitation.
Perhaps fish pedicures solely for aesthetic reasons should not be practiced because of the potential infection risk – as well as the harm (to both humans and fish) and overharvesting of the fish. If used properly, these fish, however, could be an aid in treating certain skin pathologies.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The magic of microblading
The use of permanent cosmetics dates back thousands of years in history. and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.
The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.
Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.
While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.
The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.
Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.
Like other cosmetic treatments, cheaper is never better.
Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at dermnews@mdedge.com. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.
The use of permanent cosmetics dates back thousands of years in history. and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.
The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.
Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.
While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.
The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.
Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.
Like other cosmetic treatments, cheaper is never better.
Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at dermnews@mdedge.com. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.
The use of permanent cosmetics dates back thousands of years in history. and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.
The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.
Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.
While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.
The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.
Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.
Like other cosmetic treatments, cheaper is never better.
Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at dermnews@mdedge.com. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.
Collagen drinks – do they really work?
The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.
Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?
We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?
Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?
Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.
Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?
We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?
Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?
Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.
Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?
We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?
Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?
Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
Skin rollers
, but only a few actually have any scientific data or clinical studies supporting their claims. In general, these rollers promise to increase collagen, depuff the skin, lift and firm, increase circulation, increase oxygenation, and decrease inflammation. But no clinically significant results have been reported with most of these over-the-counter devices. Furthermore, not every roller is meant for every skin type – and some should stay within the hands of an experienced professional.
Ice rollers have been used for many years and are very effective to cool the skin for in-office procedures. They are drum-shaped stainless steel rollers that are left in the freezer and cool the epidermis upon application. At-home ice rollers cause immediate vasoconstriction and are a quick fix for periorbital edema or skin erythema. Three-dimensional roller face massagers are simply a massage tool and can be used on any skin type to increase facial circulation; they do not provide any visible clinical benefits. Nanocurrent or vibrating rollers use nanocurrents and vibration alongside a conductor gel to glide across the skin; they massage the skin and help topically applied agents penetrate into the stratum corneum.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Orentreich DS et al. Dermatol Surg. 1995;21(6):543-9.
Aust MC et al. Plast Reconstr Surg. 2008;21(4):1421-9.Fernandes D et al. Clin Dermatol. 2008 Mar-Apr;26(2):192-9.
Nair PA et al. GMJ. 2014;69:24-7.
, but only a few actually have any scientific data or clinical studies supporting their claims. In general, these rollers promise to increase collagen, depuff the skin, lift and firm, increase circulation, increase oxygenation, and decrease inflammation. But no clinically significant results have been reported with most of these over-the-counter devices. Furthermore, not every roller is meant for every skin type – and some should stay within the hands of an experienced professional.
Ice rollers have been used for many years and are very effective to cool the skin for in-office procedures. They are drum-shaped stainless steel rollers that are left in the freezer and cool the epidermis upon application. At-home ice rollers cause immediate vasoconstriction and are a quick fix for periorbital edema or skin erythema. Three-dimensional roller face massagers are simply a massage tool and can be used on any skin type to increase facial circulation; they do not provide any visible clinical benefits. Nanocurrent or vibrating rollers use nanocurrents and vibration alongside a conductor gel to glide across the skin; they massage the skin and help topically applied agents penetrate into the stratum corneum.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Orentreich DS et al. Dermatol Surg. 1995;21(6):543-9.
Aust MC et al. Plast Reconstr Surg. 2008;21(4):1421-9.Fernandes D et al. Clin Dermatol. 2008 Mar-Apr;26(2):192-9.
Nair PA et al. GMJ. 2014;69:24-7.
, but only a few actually have any scientific data or clinical studies supporting their claims. In general, these rollers promise to increase collagen, depuff the skin, lift and firm, increase circulation, increase oxygenation, and decrease inflammation. But no clinically significant results have been reported with most of these over-the-counter devices. Furthermore, not every roller is meant for every skin type – and some should stay within the hands of an experienced professional.
Ice rollers have been used for many years and are very effective to cool the skin for in-office procedures. They are drum-shaped stainless steel rollers that are left in the freezer and cool the epidermis upon application. At-home ice rollers cause immediate vasoconstriction and are a quick fix for periorbital edema or skin erythema. Three-dimensional roller face massagers are simply a massage tool and can be used on any skin type to increase facial circulation; they do not provide any visible clinical benefits. Nanocurrent or vibrating rollers use nanocurrents and vibration alongside a conductor gel to glide across the skin; they massage the skin and help topically applied agents penetrate into the stratum corneum.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@mdedge.com. They had no relevant disclosures.
References
Orentreich DS et al. Dermatol Surg. 1995;21(6):543-9.
Aust MC et al. Plast Reconstr Surg. 2008;21(4):1421-9.Fernandes D et al. Clin Dermatol. 2008 Mar-Apr;26(2):192-9.
Nair PA et al. GMJ. 2014;69:24-7.
Laser tattoo removal clinic closures: Are patients getting scammed?
A patient came into my office recently and informed me that a well-known laser tattoo removal clinic in Los Angeles that she had gone to for years had suddenly shut down. All locations closed. No one answered the phone. No information about the remainder of the money in the package she bought. After researching online, she found that the Better Business Bureau did not yet have much information but doubted she would get her money back. This particular patient had not gone to the clinic in more than a year but had a residual tattoo and had looked into returning for more treatments and using the remainder of her package. She was one of the lucky ones. Other online discussion groups had entries from numerous patients who paid for packages (some costing thousands of dollars) for multiple laser treatments. Some had paid recently and had not yet received a single treatment and were left with no information about their options or where their money had gone.
It turns out in Southern California and Texas. No notification was given to the patients in advance. Nor was any notification given to some of the staff members, who complained online that they suddenly lost their jobs. Ironically, the same clinics had posted a letter online several years ago honoring discounted first treatments and packages for patients of a different laser tattoo clinic that had suddenly shut down.
So how often is this happening? Are all these clinics owned by the same people? And what can our specialty do to protect patients from being scammed and, for that matter, receiving treatment from professionals who may not be properly trained or experienced to provide that treatment?
In a world in which insurance reimbursements keep getting cut, more and more medical professionals – physicians and nonphysicians alike – are looking to fee-for-service procedures and practice models for increasing income. Sometimes, this may involve physicians delegating procedures to nonphysicians. Franchised clinics open up with a physician to “oversee” the clinic, while extenders often perform the procedures (many times without the physician present). Physicians who are neither trained nor specialized to do certain cosmetic procedures start to perform them. Patients get used to receiving treatments from nonphysicians or from physicians who are not specialized to perform cosmetic procedures, and then may devalue the procedure, feeling it’s unnecessary for a physician or a specialized physician to perform it.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.
A patient came into my office recently and informed me that a well-known laser tattoo removal clinic in Los Angeles that she had gone to for years had suddenly shut down. All locations closed. No one answered the phone. No information about the remainder of the money in the package she bought. After researching online, she found that the Better Business Bureau did not yet have much information but doubted she would get her money back. This particular patient had not gone to the clinic in more than a year but had a residual tattoo and had looked into returning for more treatments and using the remainder of her package. She was one of the lucky ones. Other online discussion groups had entries from numerous patients who paid for packages (some costing thousands of dollars) for multiple laser treatments. Some had paid recently and had not yet received a single treatment and were left with no information about their options or where their money had gone.
It turns out in Southern California and Texas. No notification was given to the patients in advance. Nor was any notification given to some of the staff members, who complained online that they suddenly lost their jobs. Ironically, the same clinics had posted a letter online several years ago honoring discounted first treatments and packages for patients of a different laser tattoo clinic that had suddenly shut down.
So how often is this happening? Are all these clinics owned by the same people? And what can our specialty do to protect patients from being scammed and, for that matter, receiving treatment from professionals who may not be properly trained or experienced to provide that treatment?
In a world in which insurance reimbursements keep getting cut, more and more medical professionals – physicians and nonphysicians alike – are looking to fee-for-service procedures and practice models for increasing income. Sometimes, this may involve physicians delegating procedures to nonphysicians. Franchised clinics open up with a physician to “oversee” the clinic, while extenders often perform the procedures (many times without the physician present). Physicians who are neither trained nor specialized to do certain cosmetic procedures start to perform them. Patients get used to receiving treatments from nonphysicians or from physicians who are not specialized to perform cosmetic procedures, and then may devalue the procedure, feeling it’s unnecessary for a physician or a specialized physician to perform it.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.
A patient came into my office recently and informed me that a well-known laser tattoo removal clinic in Los Angeles that she had gone to for years had suddenly shut down. All locations closed. No one answered the phone. No information about the remainder of the money in the package she bought. After researching online, she found that the Better Business Bureau did not yet have much information but doubted she would get her money back. This particular patient had not gone to the clinic in more than a year but had a residual tattoo and had looked into returning for more treatments and using the remainder of her package. She was one of the lucky ones. Other online discussion groups had entries from numerous patients who paid for packages (some costing thousands of dollars) for multiple laser treatments. Some had paid recently and had not yet received a single treatment and were left with no information about their options or where their money had gone.
It turns out in Southern California and Texas. No notification was given to the patients in advance. Nor was any notification given to some of the staff members, who complained online that they suddenly lost their jobs. Ironically, the same clinics had posted a letter online several years ago honoring discounted first treatments and packages for patients of a different laser tattoo clinic that had suddenly shut down.
So how often is this happening? Are all these clinics owned by the same people? And what can our specialty do to protect patients from being scammed and, for that matter, receiving treatment from professionals who may not be properly trained or experienced to provide that treatment?
In a world in which insurance reimbursements keep getting cut, more and more medical professionals – physicians and nonphysicians alike – are looking to fee-for-service procedures and practice models for increasing income. Sometimes, this may involve physicians delegating procedures to nonphysicians. Franchised clinics open up with a physician to “oversee” the clinic, while extenders often perform the procedures (many times without the physician present). Physicians who are neither trained nor specialized to do certain cosmetic procedures start to perform them. Patients get used to receiving treatments from nonphysicians or from physicians who are not specialized to perform cosmetic procedures, and then may devalue the procedure, feeling it’s unnecessary for a physician or a specialized physician to perform it.
Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.
Choosing noninvasive tightening treatments wisely
We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.
The treatment options are varied and include radio-frequency, ultrasound, and fractional resurfacing. There are numerous devices on the market that deliver energy into the dermis thereby causing collagen contraction and neocollagenesis. In my experience, the more “invasive” procedures or surgical tissue-tightening procedures provide the most reliable and immediate results. The radio-frequency and ultrasound devices that are “noninvasive” have little down-time, but multiple treatments are often needed and have inconsistent outcomes.
The technology for noninvasive modalities has improved over the last decade, but there are still no longterm clinical data, and results are highly varied. The difference in protocols and outcomes depends on proper patient selection, method of energy delivery, and sequential treatments.
We believe the optimal way to utilize these devices is as a combination approach with other procedures to optimize skin tightening and improvement in tone and texture. Tissue-tightening devices should be used with fractional ablative or nonablative resurfacing, fillers, and toxins. Often, we recommend starting with fillers and resurfacing treatments first to get the immediate “wow” factor and achieve immediate patient satisfaction. If patients want to then add skin tightening, this can be useful as an adjunct treatment and can even be used as a maintenance approach once per year. Actinic damage is also highly predictive of the degree of tissue laxity. Treating both the dermis and epidermis together delivers more immediate results. Using a fractional resurfacing device provides tissue tightening, improved skin color, decreased discoloration, and a reduction in the number of brown spots and freckles. Patients usually only need one to two treatments, there is minimal downtime, and satisfaction is very high.
In my practice, I choose fractional resurfacing treatments first. If patients want additional tissue tightening, radio-frequency is used as an adjunct treatment. This keeps costs lower, patients happier, and results more attainable.
When choosing devices for my practice, I follow a simple mantra: highest satisfaction per patient dollar spent. Happy patients build trust and integrity for the provider and practice. Don’t just buy a device because others are using it, and don’t just recommend a device because you have it.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They have no relevant disclosures.
We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.
The treatment options are varied and include radio-frequency, ultrasound, and fractional resurfacing. There are numerous devices on the market that deliver energy into the dermis thereby causing collagen contraction and neocollagenesis. In my experience, the more “invasive” procedures or surgical tissue-tightening procedures provide the most reliable and immediate results. The radio-frequency and ultrasound devices that are “noninvasive” have little down-time, but multiple treatments are often needed and have inconsistent outcomes.
The technology for noninvasive modalities has improved over the last decade, but there are still no longterm clinical data, and results are highly varied. The difference in protocols and outcomes depends on proper patient selection, method of energy delivery, and sequential treatments.
We believe the optimal way to utilize these devices is as a combination approach with other procedures to optimize skin tightening and improvement in tone and texture. Tissue-tightening devices should be used with fractional ablative or nonablative resurfacing, fillers, and toxins. Often, we recommend starting with fillers and resurfacing treatments first to get the immediate “wow” factor and achieve immediate patient satisfaction. If patients want to then add skin tightening, this can be useful as an adjunct treatment and can even be used as a maintenance approach once per year. Actinic damage is also highly predictive of the degree of tissue laxity. Treating both the dermis and epidermis together delivers more immediate results. Using a fractional resurfacing device provides tissue tightening, improved skin color, decreased discoloration, and a reduction in the number of brown spots and freckles. Patients usually only need one to two treatments, there is minimal downtime, and satisfaction is very high.
In my practice, I choose fractional resurfacing treatments first. If patients want additional tissue tightening, radio-frequency is used as an adjunct treatment. This keeps costs lower, patients happier, and results more attainable.
When choosing devices for my practice, I follow a simple mantra: highest satisfaction per patient dollar spent. Happy patients build trust and integrity for the provider and practice. Don’t just buy a device because others are using it, and don’t just recommend a device because you have it.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They have no relevant disclosures.
We all have one priority with all of our facial rejuvenation patients: Having happy, satisfied patients. With this in mind, I find I am torn by the armamentarium of noninvasive tightening devices to choose from. What are the critical factors in choosing a platform for your practice? Most practices look at pain, downtime, cost, and the number of treatments necessary to reach the expected outcome.
The treatment options are varied and include radio-frequency, ultrasound, and fractional resurfacing. There are numerous devices on the market that deliver energy into the dermis thereby causing collagen contraction and neocollagenesis. In my experience, the more “invasive” procedures or surgical tissue-tightening procedures provide the most reliable and immediate results. The radio-frequency and ultrasound devices that are “noninvasive” have little down-time, but multiple treatments are often needed and have inconsistent outcomes.
The technology for noninvasive modalities has improved over the last decade, but there are still no longterm clinical data, and results are highly varied. The difference in protocols and outcomes depends on proper patient selection, method of energy delivery, and sequential treatments.
We believe the optimal way to utilize these devices is as a combination approach with other procedures to optimize skin tightening and improvement in tone and texture. Tissue-tightening devices should be used with fractional ablative or nonablative resurfacing, fillers, and toxins. Often, we recommend starting with fillers and resurfacing treatments first to get the immediate “wow” factor and achieve immediate patient satisfaction. If patients want to then add skin tightening, this can be useful as an adjunct treatment and can even be used as a maintenance approach once per year. Actinic damage is also highly predictive of the degree of tissue laxity. Treating both the dermis and epidermis together delivers more immediate results. Using a fractional resurfacing device provides tissue tightening, improved skin color, decreased discoloration, and a reduction in the number of brown spots and freckles. Patients usually only need one to two treatments, there is minimal downtime, and satisfaction is very high.
In my practice, I choose fractional resurfacing treatments first. If patients want additional tissue tightening, radio-frequency is used as an adjunct treatment. This keeps costs lower, patients happier, and results more attainable.
When choosing devices for my practice, I follow a simple mantra: highest satisfaction per patient dollar spent. Happy patients build trust and integrity for the provider and practice. Don’t just buy a device because others are using it, and don’t just recommend a device because you have it.
Dr. Lily Talakoub and Dr. Naissan Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They have no relevant disclosures.
High-dose hydrogen peroxide for SKs
Formerly known as A-101, . It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.
Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.
In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at dermnews@frontlinemedcom.com.
Formerly known as A-101, . It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.
Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.
In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at dermnews@frontlinemedcom.com.
Formerly known as A-101, . It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.
Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.
In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at dermnews@frontlinemedcom.com.