Naissan Wesley, MD

 

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Cosmetic procedures are being done by everyone and anyone nowadays. Injectables, lasers, resurfacing, you name it; they can be done by nurses, physician assistants, non–board certified doctors of all specialties, and even dentists. And online discount sites offer a platform for marketing.

After falling victim to this fad myself, I realize that it was the worst business decision I have ever made – from the perspectives of the risks to the patient and the risks to the business.

The risks to the patient are transparent. The most obvious risk is the abundance of inexperienced injectors doing procedures. Self explanatory. Discount sites obtain medical license information prior to approving any medical treatment; however, not everyone with a medical license should be doing cosmetic procedures.

The second risk is a lack of proper evaluation and management, which leads to poor medical management and dissatisfaction. We should be approaching each cosmetic patient with treatments and procedures that are right for them, their skin, their medical history, their anatomy, and their specific needs. There is no screening through these sites. Patients buy the service, and even if the procedure is not right for them, they expect the service. Even if there is a statement on a site that services are contingent on screening, the promise of the service has already been made. If you do not provide the service, often the now-disgruntled patient will complain about you, your staff, your ethics, to anyone and everyone. If you do the procedure despite your best intentions, you are setting yourself up for disaster ... complications, unsatisfied patients, and unmet expectations. There is a reason consultations are necessary.

Third, the margins on this type of service are negligible. If a practice if offering injectable treatments at a too-good-to-be-true price, it probably is. Neurotoxins might be diluted, fillers could be mixed, products may be purchased from substandard overseas manufacturers, and subpar treatments and bad results can happen.

The risks to the practice, while not as transparent, are often delayed and everlasting.

First, there are the legal implications of fee-splitting in some states, such as New York and California. The laws are set up to avoid conflicts of interest and kickbacks among health care organizations. An organization cannot be paid for referring a patient to a medical practice. Second, a customer who is willing to buy a discounted cosmetic procedure offers a reason enough not to do that treatment. Many online bargain shoppers are dissatisfied customers or patients that you do not want do a cosmetic procedure on in the first place. Finally, the cost of acquiring new patients through marketing is daunting for small businesses and what these discounters offer are “free” marketing tools. Through geolocation and search engine optimization, they increase brand visibility and deliver a steady influx of customers. However, very few of the massive surge of these initial clients become return customers and, given the hefty discount and processing fees involved, the business model may not prove to be worthwhile.

This approach fosters disloyalty. If a customer can’t buy more than one deal, he or she will more than likely go elsewhere. If you are delivering substandard care, you are posing a risk to your own reputation, and those unsatisfied customers may be more likely to post negative reviews, dismantling the integrity of your practice. A study described in a 2011 article in MIT Technology Review looked at how businesses that did discount deals fared on Yelp. The study showed that, although the number of reviews increased significantly after the deal, the average rating scores from reviewers on Yelp were about 10% lower than others’ reviews. For a small business, this can be debilitating and could lead to the demise of the brand.

Everyone loves a deal, myself included. However, for your practice, there are health and ethical issues with these discount businesses. Good treatments aren’t cheap, and cheap treatments aren’t good.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

 

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Cosmetic procedures are being done by everyone and anyone nowadays. Injectables, lasers, resurfacing, you name it; they can be done by nurses, physician assistants, non–board certified doctors of all specialties, and even dentists. And online discount sites offer a platform for marketing.

After falling victim to this fad myself, I realize that it was the worst business decision I have ever made – from the perspectives of the risks to the patient and the risks to the business.

The risks to the patient are transparent. The most obvious risk is the abundance of inexperienced injectors doing procedures. Self explanatory. Discount sites obtain medical license information prior to approving any medical treatment; however, not everyone with a medical license should be doing cosmetic procedures.

The second risk is a lack of proper evaluation and management, which leads to poor medical management and dissatisfaction. We should be approaching each cosmetic patient with treatments and procedures that are right for them, their skin, their medical history, their anatomy, and their specific needs. There is no screening through these sites. Patients buy the service, and even if the procedure is not right for them, they expect the service. Even if there is a statement on a site that services are contingent on screening, the promise of the service has already been made. If you do not provide the service, often the now-disgruntled patient will complain about you, your staff, your ethics, to anyone and everyone. If you do the procedure despite your best intentions, you are setting yourself up for disaster ... complications, unsatisfied patients, and unmet expectations. There is a reason consultations are necessary.

Third, the margins on this type of service are negligible. If a practice if offering injectable treatments at a too-good-to-be-true price, it probably is. Neurotoxins might be diluted, fillers could be mixed, products may be purchased from substandard overseas manufacturers, and subpar treatments and bad results can happen.

The risks to the practice, while not as transparent, are often delayed and everlasting.

First, there are the legal implications of fee-splitting in some states, such as New York and California. The laws are set up to avoid conflicts of interest and kickbacks among health care organizations. An organization cannot be paid for referring a patient to a medical practice. Second, a customer who is willing to buy a discounted cosmetic procedure offers a reason enough not to do that treatment. Many online bargain shoppers are dissatisfied customers or patients that you do not want do a cosmetic procedure on in the first place. Finally, the cost of acquiring new patients through marketing is daunting for small businesses and what these discounters offer are “free” marketing tools. Through geolocation and search engine optimization, they increase brand visibility and deliver a steady influx of customers. However, very few of the massive surge of these initial clients become return customers and, given the hefty discount and processing fees involved, the business model may not prove to be worthwhile.

This approach fosters disloyalty. If a customer can’t buy more than one deal, he or she will more than likely go elsewhere. If you are delivering substandard care, you are posing a risk to your own reputation, and those unsatisfied customers may be more likely to post negative reviews, dismantling the integrity of your practice. A study described in a 2011 article in MIT Technology Review looked at how businesses that did discount deals fared on Yelp. The study showed that, although the number of reviews increased significantly after the deal, the average rating scores from reviewers on Yelp were about 10% lower than others’ reviews. For a small business, this can be debilitating and could lead to the demise of the brand.

Everyone loves a deal, myself included. However, for your practice, there are health and ethical issues with these discount businesses. Good treatments aren’t cheap, and cheap treatments aren’t good.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

 

I admit it ... I am a victim too. The hype was real. Offer a service, at a hefty discount, and increase your patient volume. I didn’t need to increase my patient load. But with more overhead, getting the new providers in my practice busy fast was alluring. There are, however, so many inherent risks to discounting. So I offer you this column as my own version of a consumer alert on discount coupon sites.

Getty Images/Thinkstock

Cosmetic procedures are being done by everyone and anyone nowadays. Injectables, lasers, resurfacing, you name it; they can be done by nurses, physician assistants, non–board certified doctors of all specialties, and even dentists. And online discount sites offer a platform for marketing.

After falling victim to this fad myself, I realize that it was the worst business decision I have ever made – from the perspectives of the risks to the patient and the risks to the business.

The risks to the patient are transparent. The most obvious risk is the abundance of inexperienced injectors doing procedures. Self explanatory. Discount sites obtain medical license information prior to approving any medical treatment; however, not everyone with a medical license should be doing cosmetic procedures.

The second risk is a lack of proper evaluation and management, which leads to poor medical management and dissatisfaction. We should be approaching each cosmetic patient with treatments and procedures that are right for them, their skin, their medical history, their anatomy, and their specific needs. There is no screening through these sites. Patients buy the service, and even if the procedure is not right for them, they expect the service. Even if there is a statement on a site that services are contingent on screening, the promise of the service has already been made. If you do not provide the service, often the now-disgruntled patient will complain about you, your staff, your ethics, to anyone and everyone. If you do the procedure despite your best intentions, you are setting yourself up for disaster ... complications, unsatisfied patients, and unmet expectations. There is a reason consultations are necessary.

Third, the margins on this type of service are negligible. If a practice if offering injectable treatments at a too-good-to-be-true price, it probably is. Neurotoxins might be diluted, fillers could be mixed, products may be purchased from substandard overseas manufacturers, and subpar treatments and bad results can happen.

The risks to the practice, while not as transparent, are often delayed and everlasting.

First, there are the legal implications of fee-splitting in some states, such as New York and California. The laws are set up to avoid conflicts of interest and kickbacks among health care organizations. An organization cannot be paid for referring a patient to a medical practice. Second, a customer who is willing to buy a discounted cosmetic procedure offers a reason enough not to do that treatment. Many online bargain shoppers are dissatisfied customers or patients that you do not want do a cosmetic procedure on in the first place. Finally, the cost of acquiring new patients through marketing is daunting for small businesses and what these discounters offer are “free” marketing tools. Through geolocation and search engine optimization, they increase brand visibility and deliver a steady influx of customers. However, very few of the massive surge of these initial clients become return customers and, given the hefty discount and processing fees involved, the business model may not prove to be worthwhile.

This approach fosters disloyalty. If a customer can’t buy more than one deal, he or she will more than likely go elsewhere. If you are delivering substandard care, you are posing a risk to your own reputation, and those unsatisfied customers may be more likely to post negative reviews, dismantling the integrity of your practice. A study described in a 2011 article in MIT Technology Review looked at how businesses that did discount deals fared on Yelp. The study showed that, although the number of reviews increased significantly after the deal, the average rating scores from reviewers on Yelp were about 10% lower than others’ reviews. For a small business, this can be debilitating and could lead to the demise of the brand.

Everyone loves a deal, myself included. However, for your practice, there are health and ethical issues with these discount businesses. Good treatments aren’t cheap, and cheap treatments aren’t good.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

Sisler J. Discount deals becoming medical rage. CMAJ. 2012 Feb 21;184(3):E167-8.

Krieger LM. Discount cosmetic surgery: industry trends and strategies for success. Plast Reconstr Surg. 2002 Aug;110(2):614-9.

Atiyeh BS et al. Aesthetic/Cosmetic surgery and ethical challenges. Aesthetic Plast Surg. 2008 Nov;32(6):829-39.

Groupon’s Hidden Influence on Reputation. MIT Technology Review. Sept. 12, 2011.

 

It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.

Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.

level17/thinkstock

Dermatologists can attest to the number of patients that confess that they only sometimes wear sunscreen “when outside.” If UV exposure to inside lighting has more significant effects on the skin, however, more precautions must be taken to prevent skin cancer, melasma, and other skin damage from exposure through window glass, and from fluorescent bulbs, halogen lamps, and tablet and computer screens.

A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.

Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.

Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.

Lamps that are not used for lighting also must be considered. The Food and Drug Administration recently released a consumer alert regarding the use of UV-curing lamps at nail salons because of the UV radiation emitted. Since daily use of such lamps is not common, the risk of such an exposure is low; but precautions against UV exposure have, nonetheless, been recommended. UV-protectant gloves and application of a broad spectrum sunscreen on the hands prior to use is recommended to decrease the risks of UV exposure to the hands.

In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.

In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.

Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.

Blue light has a very short wavelength with high energy. Studies have shown that permanent eye damage, including macular degeneration, from extended exposure to close-range blue light from computers and tablets is possible. Close-range blue light has been associated with increased skin melanogenesis. Skin hyperpigmentation, such as in lichen planus pigmentosus and melasma, also can be exacerbated by blue light; to prevent the worsening of such conditions, discretion is advised with regard to the use of these devices in close proximity to the skin.

The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
 

 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

References

Autoimmun Rev. 2009;8(4):320-4.

Anais Brasileiros de Dermatologia. 2015;90(4):595-7.

 

It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.

Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.

level17/thinkstock

Dermatologists can attest to the number of patients that confess that they only sometimes wear sunscreen “when outside.” If UV exposure to inside lighting has more significant effects on the skin, however, more precautions must be taken to prevent skin cancer, melasma, and other skin damage from exposure through window glass, and from fluorescent bulbs, halogen lamps, and tablet and computer screens.

A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.

Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.

Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.

Lamps that are not used for lighting also must be considered. The Food and Drug Administration recently released a consumer alert regarding the use of UV-curing lamps at nail salons because of the UV radiation emitted. Since daily use of such lamps is not common, the risk of such an exposure is low; but precautions against UV exposure have, nonetheless, been recommended. UV-protectant gloves and application of a broad spectrum sunscreen on the hands prior to use is recommended to decrease the risks of UV exposure to the hands.

In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.

In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.

Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.

Blue light has a very short wavelength with high energy. Studies have shown that permanent eye damage, including macular degeneration, from extended exposure to close-range blue light from computers and tablets is possible. Close-range blue light has been associated with increased skin melanogenesis. Skin hyperpigmentation, such as in lichen planus pigmentosus and melasma, also can be exacerbated by blue light; to prevent the worsening of such conditions, discretion is advised with regard to the use of these devices in close proximity to the skin.

The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
 

 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

References

Autoimmun Rev. 2009;8(4):320-4.

Anais Brasileiros de Dermatologia. 2015;90(4):595-7.

 

It may be surprising that there are dermatologic risks of UV exposure from lamps and other indoor light sources that we use daily. Is long-term daily exposure to presumably low-irradiance lights of clinical significance to photodermatoses? Recent findings suggest that skin protection must be practiced indoors to adequately protect the skin against UV rays.

Photodermatoses, such as lupus, actinic prurigo, and xeroderma pigmentosum, are only a few of the skin diseases that are triggered by UV exposure; however, chronic low-dose exposures to UV light, such as those associated with indoor lighting, may also be triggers of such conditions. Melasma, for example, can be triggered by heat or UV light. Chronic exposure to ambient light may darken the skin, necessitating daily UV protection in both indoor and outdoor settings.

level17/thinkstock

Dermatologists can attest to the number of patients that confess that they only sometimes wear sunscreen “when outside.” If UV exposure to inside lighting has more significant effects on the skin, however, more precautions must be taken to prevent skin cancer, melasma, and other skin damage from exposure through window glass, and from fluorescent bulbs, halogen lamps, and tablet and computer screens.

A study examining light sources in the environment of a child with xeroderma pigmentosum suggested that indoor lights emit unexpected amounts of UV light as measured by a spectral radiometer. This finding illustrated that cumulative, chronic doses of indoor lighting may be of clinical significance.

Interior lighting is also implicated in worsening of melasma and other photosensitive dermatoses. Incandescent bulbs have little to no UV irradiance. However, fluorescent lighting has been shown to increase lifetime UV exposure by 3% based on the distance the lamp is from the skin. If the lamp is close – particularly desk lamps, bed lamps, and overhead lamps – the light and heat emitted can worsen photoexacerbated dermatitidis. Avoiding close contact with the light or adding acrylic or plastic diffusers to the light can help reduce exposure.

Halogen bulbs are filled with an inert gas and a halogen, such as iodine. These bulbs are usually made of quartz because quartz is more resistant to the high heat emitted by these bulbs. But the quartz, however, does not block UV radiation, which is why manufacturers add UV-blocking agents and heat-resistant glass to block the UV; however, the amount blocked is usually unknown. As with fluorescent bulbs, the distance from the bulb is essential to protect against both the UV and heat emitted. Light-emitting diodes (LEDs) generate a light from a semiconductor material that converts blue light into white light with the use of phosphorus; LEDs do not emit UV rays and, therefore, are a safer light source for the skin.

Lamps that are not used for lighting also must be considered. The Food and Drug Administration recently released a consumer alert regarding the use of UV-curing lamps at nail salons because of the UV radiation emitted. Since daily use of such lamps is not common, the risk of such an exposure is low; but precautions against UV exposure have, nonetheless, been recommended. UV-protectant gloves and application of a broad spectrum sunscreen on the hands prior to use is recommended to decrease the risks of UV exposure to the hands.

In addition to the use of lamps, the light that passes through glass is easy to underestimate. Unlike UVB rays, UVA rays pass through glass and affect the skin. The percentage of UVA rays that pass through glass depends on the type of glass and the coating on the glass. There are three types of window glass: clear, reflective, and tinted. Clear glass allows 75% of UVA through,while reflective and tinted glass allow only 25%-50% of UVA rays to pass through. Low-emissivity glass (Low-E) is made to reduce heat transfer and is similar to clear glass. The most protective glass is laminated or UV-coated glass that filters out 95%-99% of all UVA rays. Unfortunately, most residential and commercial buildings do not have UVA protection. The use of blinds, shades, and tinted glass, and increasing the distance from windows and doors are the best methods of protection from chronic daily UVA exposures.

In most cars, windshield is made of laminated glass (two layers of glass with a layer of plastic in between), which blocks all UVB and approximately 50% of UVA rays. However, side and rear windows are often clear glass, which does not prevent UVA rays from penetrating through. Patients with photosensitive dermatoses and all melasma patients are encouraged to tint the side windows of their vehicles to reduce UVA exposures to 15%-30%. Tinting, however, must be in compliance with federally mandated standard of 70% minimum visible light transmittance. In my practice, daily UV protection is recommended for all patients, even within an automobile or in an office. Daily cumulative exposure can cause chronic skin damage and early signs of photoaging.

Other sources of indoor exposures include TV monitors, computers, tablets, and UV sterilization devices in the workplace. Older cathode ray tube screens emit UV radiation; however, newer liquid crystal display (LCD) or flat panel monitors most commonly on laptops, desktops, and mobile devices do not emit UV radiation. They do emit blue light – although a small fraction compared to that emitted by the sun. The amount of time spent in front of these screens and their proximity can pose a problem as blue light can increase reactive oxygen species, which is the most common contributor to premature aging. These devices also emit heat, which can exacerbate erythema ab igne and other heat-sensitive skin conditions.

Blue light has a very short wavelength with high energy. Studies have shown that permanent eye damage, including macular degeneration, from extended exposure to close-range blue light from computers and tablets is possible. Close-range blue light has been associated with increased skin melanogenesis. Skin hyperpigmentation, such as in lichen planus pigmentosus and melasma, also can be exacerbated by blue light; to prevent the worsening of such conditions, discretion is advised with regard to the use of these devices in close proximity to the skin.

The risks of indoor UV and blue light exposures are commonly overlooked. Skin protection with broad-spectrum sunscreen both inside and outside should be used daily for maximum protection. Care should also be taken to limit exposure times and increase distance of these objects from the skin and eyes.
 

 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

References

Autoimmun Rev. 2009;8(4):320-4.

Anais Brasileiros de Dermatologia. 2015;90(4):595-7.

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com. They had no relevant disclosures.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

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.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley 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.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley 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.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley 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.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

 

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley 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 an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

 

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley 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 an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

 

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley 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 an update by Dr. Wesley of a previous column by Dr. Talakoub.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley 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.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley 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.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley 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.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

 

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley 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.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

 

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley 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.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

 

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley 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.