Lily Talakoub, MD

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub 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. Wesley.

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub 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. Wesley.

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub 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. Wesley.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub 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.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub 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.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub 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.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology 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. Wesley.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology 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. Wesley.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology 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. Wesley.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub 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.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub 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.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub 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.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

We are so lucky to be part of a field of medicine where advances in patient treatment options continue to occur. Having been involved in the Kybella clinical trials, it is exciting and satisfactory to see a new successful aesthetic treatment come to fruition. Kybella is the first and only Food and Drug Administration–approved injectable drug to reduce the appearance of “double chin” (submental fullness associated with submental fat) in adult patients. It is a synthetic form of naturally occurring deoxycholic acid (DCA), which lyses adipocytes when properly injected into subcutaneous fat. The safe and effective use of Kybella for the treatment of subcutaneous fat outside of the submental region has not been established and is not recommended.

The drug received unanimous support from an FDA advisory panel in March based on two placebo-controlled phase III trials involving more than 1,000 adults. In over 1,600 patients treated, 79% saw great improvement. In the studies, safety and efficacy were demonstrated with treatment of up to 50 injections of 0.2 mL each of the 1% DCA solution administered in a single treatment. Up to six treatments were administered at least 1 month apart.

Serious side effects associated with injection of DCA may include injury to the marginal mandibular nerve and dysphagia, but the most common side effects are swelling, bruising, pain, numbness, redness, and areas of hardness in the treatment area. Other potential side effects include: tingling, nodule, itching, skin tightness, headache, alopecia, and skin ulceration. In the studies, all cases of marginal mandibular nerve injury, manifesting as an asymmetric smile or facial muscle weakness, resolved spontaneously (range 1-298 days, median 44 days). Dysphagia occurred in the clinical trials as a result of administration site reactions (for example, pain, swelling, and induration in the submental area). Cases of dysphagia resolved spontaneously (range 1-81 days, median 3 days).

Caution should be taken in patients with a history of medical conditions in the neck area, difficulty swallowing, bleeding problems, or who take blood thinners. Likewise, caution should be used in patients who are or plan to become pregnant or breastfeed as Kybella has not been studied in pregnant or breastfeeding patients. Injection is contraindicated in the presence of infection at injection sites. Kybella only should be administered by a trained health care professional.

In addition to assessing whether not the patient is an ideal candidate, setting realistic expectations, and counseling about potential side effects, consultation also should include preprocedure photographs in the Frankfurt plane. Patients with moderate to severe convexity or fullness of the submental area are ideal candidates for the procedure. Those with little submental fat and excessive skin laxity may not be good candidates for this procedure and should consider a neck lift surgery as an alternative. Patients with prominent platysmal bands prior to procedure still may notice these bands after the procedure and may consider botulinum toxin injections or platysmal banding to treat these. While the active ingredient targets fat, some beneficial skin tightening may occur as a result of inflammation and fibrosis.

After photographs are taken, it is highly recommended to mark out specific anatomic landmarks on the patient, to avoid injury to the marginal mandibular nerve, salivary glands, lymph nodes, and the subhyoid region.

The procedure takes about 15-20 minutes with a short preparation time involved. Antihistamines and anti-inflammatory medications such as loratadine and ibuprofen may be given before the procedure to help reduce risk of discomfort and edema often experienced after injection. Preprocedure injection with local anesthetic also is recommended.

Once the treatment area is demarcated with a grid placed on the patient’s skin, injections of 0.2 mL of DCA are performed with a 30-gauge ½ inch needle. The product is supplied in a box with four 2-mL vials (10 mg/mL). No refrigeration is required. Once a vial is opened, it should only be used on one patient. A maximum of up to 10 mL may be injected in one patient in one session. Ice may applied after treatment. Postprocedure swelling and throbbing can be expected for several days and may rarely last up to 1 month. Patients may require two to six treatments spaced at least 1 month apart.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley. Dr. Wesley was an investigator in the phase III Kybella clinical trials. E-mail her at dermnews@frontlinemedcom.com.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. 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.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.