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Subscription services a consideration for aesthetic patients
According to W. Grant Stevens, MD, an estimated 73% of aesthetic patients fall short when it comes to compliance with recommended treatment intervals for toxins, fillers, and other procedures.
“When we talk about how often the average patient should be treated with Botox, for instance, we say every 3-4 months,” Dr. Stevens, founder and CEO of Marina Plastic Surgery in Marina Del Rey, Calif., said during the virtual annual Masters of Aesthetics Symposium. But in reality, he added, “it’s more like every 7 months.” A 2015 survey of 23 Bay Area aesthetic practices conducted by HintMD found that 73% of patients were noncompliant and that they came in fewer than 3-4 times per year for treatments. “Not only did they come in infrequently, but they oftentimes were undercorrected and the revenue was being left on the table because of discounting and undercorrection,” said Dr. Stevens, who is also a professor of surgery in the division of plastic surgery at the University of Southern California, Los Angeles.
On average, each patient from the 23 practices surveyed spent $601.88 on treatments 1.44 times per year, yet the industry standard for neuromodulators is 3-4 times per year and every 2 months for HydraFacials and med spa facials. “What’s the problem?” he asked “Why are we falling off? For our practices, noncompliance leads to unhappy, undertreated patients, so they may write negative reviews. In addition to that, we lose revenue.” He cited results from a 2016 focus group of aesthetic patients who were asked about the perceived barriers to treatment compliance. More than two-thirds (68%) said cost was the issue, followed by the number of treatments required (43%) and effectiveness (16%).
Three years ago, Dr. Stevens used the HintMD platform to implement a treatment plan subscription service to 472 active members of his practice. Prior to implementation, patients were coming in for treatment with toxins an average of 1.8 times per year. After implementation, that rose to an average of 3.1 times per year. “That was almost an $800 incremental average increase spent on toxins alone,” Dr. Stevens said. “More importantly, the patients were therapeutic all year long.” With toxin and filler services combined, the average increased income grew to more than $1,100 per patient, which translated into increased annual revenue of $519,200.
Dr. Stevens said that many of his patients favor subscription services because most use them in other aspects of their lives, such as with Amazon Prime, Blue Apron, and Netflix. “They like it because it is personalized and customized,” he said. “If we want to adjust the amount of toxin or filler, we can do it that very day, and it’s customized for them. It’s not a one-size-fits-all program. It also allows them to have convenient, smaller monthly payments. That’s the key. That way, they budget. So, if they’re spending $200 a month or $500 a month or $1,000 a month, it’s a convenient monthly payment.”
Dr. Stevens disclosed that he is an adviser to Viveve, Venus, Aesthetics Biomedical, Alastin, Cypris Medical, Allergan, CoolSculpting, HydraFacial, Revance, Ampersand, and HintMD.
According to W. Grant Stevens, MD, an estimated 73% of aesthetic patients fall short when it comes to compliance with recommended treatment intervals for toxins, fillers, and other procedures.
“When we talk about how often the average patient should be treated with Botox, for instance, we say every 3-4 months,” Dr. Stevens, founder and CEO of Marina Plastic Surgery in Marina Del Rey, Calif., said during the virtual annual Masters of Aesthetics Symposium. But in reality, he added, “it’s more like every 7 months.” A 2015 survey of 23 Bay Area aesthetic practices conducted by HintMD found that 73% of patients were noncompliant and that they came in fewer than 3-4 times per year for treatments. “Not only did they come in infrequently, but they oftentimes were undercorrected and the revenue was being left on the table because of discounting and undercorrection,” said Dr. Stevens, who is also a professor of surgery in the division of plastic surgery at the University of Southern California, Los Angeles.
On average, each patient from the 23 practices surveyed spent $601.88 on treatments 1.44 times per year, yet the industry standard for neuromodulators is 3-4 times per year and every 2 months for HydraFacials and med spa facials. “What’s the problem?” he asked “Why are we falling off? For our practices, noncompliance leads to unhappy, undertreated patients, so they may write negative reviews. In addition to that, we lose revenue.” He cited results from a 2016 focus group of aesthetic patients who were asked about the perceived barriers to treatment compliance. More than two-thirds (68%) said cost was the issue, followed by the number of treatments required (43%) and effectiveness (16%).
Three years ago, Dr. Stevens used the HintMD platform to implement a treatment plan subscription service to 472 active members of his practice. Prior to implementation, patients were coming in for treatment with toxins an average of 1.8 times per year. After implementation, that rose to an average of 3.1 times per year. “That was almost an $800 incremental average increase spent on toxins alone,” Dr. Stevens said. “More importantly, the patients were therapeutic all year long.” With toxin and filler services combined, the average increased income grew to more than $1,100 per patient, which translated into increased annual revenue of $519,200.
Dr. Stevens said that many of his patients favor subscription services because most use them in other aspects of their lives, such as with Amazon Prime, Blue Apron, and Netflix. “They like it because it is personalized and customized,” he said. “If we want to adjust the amount of toxin or filler, we can do it that very day, and it’s customized for them. It’s not a one-size-fits-all program. It also allows them to have convenient, smaller monthly payments. That’s the key. That way, they budget. So, if they’re spending $200 a month or $500 a month or $1,000 a month, it’s a convenient monthly payment.”
Dr. Stevens disclosed that he is an adviser to Viveve, Venus, Aesthetics Biomedical, Alastin, Cypris Medical, Allergan, CoolSculpting, HydraFacial, Revance, Ampersand, and HintMD.
According to W. Grant Stevens, MD, an estimated 73% of aesthetic patients fall short when it comes to compliance with recommended treatment intervals for toxins, fillers, and other procedures.
“When we talk about how often the average patient should be treated with Botox, for instance, we say every 3-4 months,” Dr. Stevens, founder and CEO of Marina Plastic Surgery in Marina Del Rey, Calif., said during the virtual annual Masters of Aesthetics Symposium. But in reality, he added, “it’s more like every 7 months.” A 2015 survey of 23 Bay Area aesthetic practices conducted by HintMD found that 73% of patients were noncompliant and that they came in fewer than 3-4 times per year for treatments. “Not only did they come in infrequently, but they oftentimes were undercorrected and the revenue was being left on the table because of discounting and undercorrection,” said Dr. Stevens, who is also a professor of surgery in the division of plastic surgery at the University of Southern California, Los Angeles.
On average, each patient from the 23 practices surveyed spent $601.88 on treatments 1.44 times per year, yet the industry standard for neuromodulators is 3-4 times per year and every 2 months for HydraFacials and med spa facials. “What’s the problem?” he asked “Why are we falling off? For our practices, noncompliance leads to unhappy, undertreated patients, so they may write negative reviews. In addition to that, we lose revenue.” He cited results from a 2016 focus group of aesthetic patients who were asked about the perceived barriers to treatment compliance. More than two-thirds (68%) said cost was the issue, followed by the number of treatments required (43%) and effectiveness (16%).
Three years ago, Dr. Stevens used the HintMD platform to implement a treatment plan subscription service to 472 active members of his practice. Prior to implementation, patients were coming in for treatment with toxins an average of 1.8 times per year. After implementation, that rose to an average of 3.1 times per year. “That was almost an $800 incremental average increase spent on toxins alone,” Dr. Stevens said. “More importantly, the patients were therapeutic all year long.” With toxin and filler services combined, the average increased income grew to more than $1,100 per patient, which translated into increased annual revenue of $519,200.
Dr. Stevens said that many of his patients favor subscription services because most use them in other aspects of their lives, such as with Amazon Prime, Blue Apron, and Netflix. “They like it because it is personalized and customized,” he said. “If we want to adjust the amount of toxin or filler, we can do it that very day, and it’s customized for them. It’s not a one-size-fits-all program. It also allows them to have convenient, smaller monthly payments. That’s the key. That way, they budget. So, if they’re spending $200 a month or $500 a month or $1,000 a month, it’s a convenient monthly payment.”
Dr. Stevens disclosed that he is an adviser to Viveve, Venus, Aesthetics Biomedical, Alastin, Cypris Medical, Allergan, CoolSculpting, HydraFacial, Revance, Ampersand, and HintMD.
FROM MOA 2020
Dermatologists’ role in the development of the skin care industry
This is the third in a series of columns discussing the important roles that dermatologists have played in the skin care industry. with the cosmetic industry, rather than developing their own skin care lines.
Norman Orentreich, MD
Dr. Orentreich was a successful New York City dermatologist and the first to perform hair transplants. This new technique brought him fame and notoriety and arguably made him the first “celebrity dermatologist.” (He was also a member of the original advisory board of Dermatology News, at that time Skin & Allergy News, in January 1970.) Dr. Orentreich was a seminal figure in the trend to link the cosmetic industry and dermatology. In August 1967, Vogue magazine1 published an article on him, titled “Can Great Skin be Created?” This popular article caught the attention of Leonard Lauder, of Estée Lauder, who recruited Dr. Orentreich to help create the skin care line Clinique. Clinique was intended to be a brand with a medical look that promoted its products as “allergy tested,” with packaging that has an antiseptic look and beauty counter salespeople wearing white coats.
Dr. Orentreich’s input into the development of a skin type–based skin care line was fundamental to the development of this brand. The four-question questionnaire with an iconic plastic lever that customers slide left or right instantly provided them with an assessment of their skin type at the beauty counter, with one of four skin types: Very Dry to Dry Skin (Skin Type 1), Dry Combination (Skin Type 2), Combination Oily (Skin Type 3), and Oily (Skin Type 4).
Although this skin-typing system was not scientifically accurate (there is no scientific definition of combination skin), it was reminiscent of the system developed by cosmetic company tycoon Helena Rubinstein in the 1940s that classified people into four skin types: oily, dry, combination, and sensitive. Clinique became a blockbuster skin care brand and was one of the first developed by a dermatologist – although Dr. Orentreich did not put his name on it.
In 1972, Dr. Orentreich filed a patent2 for an exfoliating pad for the skin that later became known as the “Buf-Puf.” I heard years ago that he got the idea from the machines used to buff the floors in the hospital. The buffing pad had a hole in the center where the machine attached. Dr. Orentreich purportedly thought “I wonder what they do with the cut-out centers?” He looked into this, and subsequently used the centers to create the Buf-Puf. I cannot find a reference for this, but I love this story and hope it’s true. If any readers have any knowledge of this, please let me know, so I can amend my story if it is incorrect.
Almay
Almay, an amalgamation of the founders’ names, Alfred and Fanny May Woititz, was the first hypoallergenic brand, established in 1931, and the first to provide hypoallergenic cosmetics, long before Clinique. In addition, the company was the first skin care brand to become available by prescription only (as it was initially), fully disclose all individual ingredients in its products (well before this became mandatory in 1976), provide totally fragrance-free products, develop a hypoallergenic fragrance – and provide patch tests and other materials to physicians to identify contact allergens.
Over 90 years, the company was also the first among skin care brands to do the following:
- Provide custom formulations to individuals proven to be allergic to a specific ingredient, through their physicians.
- Perform a full range of premarket safety testing on all products for allergy and irritation, and test all its products for comedogenicity.
- Formulate cosmetics for use around the eye area (eye shadows and eyeliners) specifically for contact lens wearers.
- Formulate hypoallergenic regimens for specific skin types in the mass market.
- Provide a specific cosmetic regimen for acne-prone women, including a silicone-based makeup and active ingredients for treatment in cosmetics and skin care.
I recently interviewed Stanley Levy, MD, who was one of the consultants to Almay, and practices in Chapel Hill, N.C., where he has an academic niche related to skin care formulation and safety. He told me how Almay provided patch test materials to dermatologists to help identify contact dermatitis to cosmetic ingredients, and described Almay’s relationship with the dermatology field as follows: “From the outset, Almay was linked to dermatology. In 1930, a chemist and pharmacist in New York City, Al Woititz, was looking to compound cosmetics for his wife suffering from cosmetic allergies, Fannie May. He enlisted the counsel of the preeminent dermatologic expert in contact dermatitis at the time, Dr. Marion Sulzberger, to suggest ingredients to avoid. [Dr. Sulzberger was also a member of the original Dermatology News editorial advisory board.] Soon, dermatologists around New York City were recommending these formulations. This led to a product line free of the known allergens and a fledgling company trademarked as Almay. For the past 90 years, [the company] has kept a close relationship with dermatologists, well before that was the norm.”
The Almay research overseen by Dr. Levy and others contributed greatly to our understanding of the allergenicity of skin care.
Albert Kligman, MD
The turning point for the interface of dermatology with the cosmetic industry was the shift from a safety-based approach (hypoallergenic and noncomedogenic) to an emphasis on efficacy claims in the 1980s. Part of the impetus for this was the Dr. Kligman’s observation that retinoids could improve photoaging.
Dr. Kligman, a well-known dermatologist at the University of Pennsylvania, Philadelphia, showed that retinoids were an effective treatment for acne. For more about this, listen to my interview on the Dermatology Weekly podcast, with James Leyden, MD, about his work at the University of Pennsylvania with Dr. Kligman on the development of oral and topical retinoids. During Dr. Kligman’s research on acne, he noticed that wrinkles improved after treatment with tretinoin, and in 1986, he and Dr. Leyden (and several other authors) published the first article about tretinoin’s use for photoaged skin.3 This led to a double-blind study4 conducted by John J. Voorhees, MD, University of Michigan, Ann Arbor, and coauthors that showed statistically significant improvement of photoaged skin when treated with topical tretinoin. Dr. Voorhees and his group did many more studies on retinoids5,6 and photoaging7 – so many that, at one time, he was (and maybe still is) the most widely published dermatologist in the United States. These studies showed that, not only did prescription tretinoin improve the appearance of wrinkles, but so did over-the-counter retinol.8 Retinoids remain the most efficacious prescription and cosmeceutical ingredients to treat wrinkled skin.
When studies conducted by Dr. Kligman, Dr. Voorhees, and by Barbara Gilcrest, MD, 9,10 showed that retinoids improved wrinkles, a major change in the focus in the skin care industry occurred.
During the same time period, the studies on alpha hydroxy acids by Chérie Ditre, MD, Eugene Van Scott, MD, and colleages11,12; and studies by Sheldon Pinnell, MD, on Vitamin C (see part 1 of this series) all demonstrated the efficacy of cosmetic ingredients on photoaged skin. This triggered a major change in how skin care products were marketed, with an efficacy approach rather than a safety approach.
With the shift from safety (hypoallergenic and noncomedogenic issues) to efficacy claims in the 1980s, and as nondrug active ingredients like retinol were shown to have biologic effects, the lines between the Food and Drug Administration’s definition of a drug versus a cosmetic became blurred. In 1984, Dr. Kligman suggested a new classification for the ingredients that fell in the middle, proposing the term “cosmeceutical” and thus, the concept of a cosmeceutical was introduced. To this day, cosmeceutical is not an official definition and the FDA has yet to deal with it as a quasi-drug category. FDA regulations as to what constitutes a drug versus a cosmetic date back to the 1938 Food, Drug and Cosmetic Act.
Once marketing focused on efficacy, many companies made outrageous claims. During the second half of the 1980s, the FDA issued some warning letters to some companies in an effort to control these claims.
Now efficacy claims abound and we, as dermatologists, should be the experts who back up these claims with scientific data. As the cosmeceutical market has evolved and grown, consumers are bewildered by the myriad of active ingredients being promoted and the number of products in the marketplace. As dermatologic innovation has led to more efficacious active ingredients, our patients look to us as knowledgeable and credible sources of information and for recommendations about the best skin care routines for their skin issues. This is all reflected in the fact that physician-dispensed skin care is becoming the fastest growing segment in this market. It is incumbent upon dermatologists to be knowledgeable and conversant about skin care products and skin care routines, and is particularly true for those of us who sell skin care products in our offices.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Burt’s Bees, Evolus, Galderma, and Revance. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Vogue Magazine, 1967 Aug 15. “Can Great Skin be Created?”
2. https://patents.google.com/patent/US3910284.
3. Kligman AM et al. J Am Acad Dermatol. 1986 Oct;15(4 Pt 2):836-59.
4. Weiss JS et al. JAMA. 1988 Jan 22-29;259(4):527-32.
5. Goldfarb MT et al. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):645-50.
6. Ellis CN et al. J Am Acad Dermatol. 1990 Oct;23(4 Pt 1):629-37.
7. Kang S; Voorhees JJ. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S55-61.
8. Kafi R et al. Arch Dermatol. 2007 May;143(5):606-12.
9. Gilchrest BA. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):610-3.
10. Bhawan J et al. Arch Dermatol. 1991 May;127(5):666-72.
11. Griffin TD et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):196-203.
12. Ditre CM et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
This is the third in a series of columns discussing the important roles that dermatologists have played in the skin care industry. with the cosmetic industry, rather than developing their own skin care lines.
Norman Orentreich, MD
Dr. Orentreich was a successful New York City dermatologist and the first to perform hair transplants. This new technique brought him fame and notoriety and arguably made him the first “celebrity dermatologist.” (He was also a member of the original advisory board of Dermatology News, at that time Skin & Allergy News, in January 1970.) Dr. Orentreich was a seminal figure in the trend to link the cosmetic industry and dermatology. In August 1967, Vogue magazine1 published an article on him, titled “Can Great Skin be Created?” This popular article caught the attention of Leonard Lauder, of Estée Lauder, who recruited Dr. Orentreich to help create the skin care line Clinique. Clinique was intended to be a brand with a medical look that promoted its products as “allergy tested,” with packaging that has an antiseptic look and beauty counter salespeople wearing white coats.
Dr. Orentreich’s input into the development of a skin type–based skin care line was fundamental to the development of this brand. The four-question questionnaire with an iconic plastic lever that customers slide left or right instantly provided them with an assessment of their skin type at the beauty counter, with one of four skin types: Very Dry to Dry Skin (Skin Type 1), Dry Combination (Skin Type 2), Combination Oily (Skin Type 3), and Oily (Skin Type 4).
Although this skin-typing system was not scientifically accurate (there is no scientific definition of combination skin), it was reminiscent of the system developed by cosmetic company tycoon Helena Rubinstein in the 1940s that classified people into four skin types: oily, dry, combination, and sensitive. Clinique became a blockbuster skin care brand and was one of the first developed by a dermatologist – although Dr. Orentreich did not put his name on it.
In 1972, Dr. Orentreich filed a patent2 for an exfoliating pad for the skin that later became known as the “Buf-Puf.” I heard years ago that he got the idea from the machines used to buff the floors in the hospital. The buffing pad had a hole in the center where the machine attached. Dr. Orentreich purportedly thought “I wonder what they do with the cut-out centers?” He looked into this, and subsequently used the centers to create the Buf-Puf. I cannot find a reference for this, but I love this story and hope it’s true. If any readers have any knowledge of this, please let me know, so I can amend my story if it is incorrect.
Almay
Almay, an amalgamation of the founders’ names, Alfred and Fanny May Woititz, was the first hypoallergenic brand, established in 1931, and the first to provide hypoallergenic cosmetics, long before Clinique. In addition, the company was the first skin care brand to become available by prescription only (as it was initially), fully disclose all individual ingredients in its products (well before this became mandatory in 1976), provide totally fragrance-free products, develop a hypoallergenic fragrance – and provide patch tests and other materials to physicians to identify contact allergens.
Over 90 years, the company was also the first among skin care brands to do the following:
- Provide custom formulations to individuals proven to be allergic to a specific ingredient, through their physicians.
- Perform a full range of premarket safety testing on all products for allergy and irritation, and test all its products for comedogenicity.
- Formulate cosmetics for use around the eye area (eye shadows and eyeliners) specifically for contact lens wearers.
- Formulate hypoallergenic regimens for specific skin types in the mass market.
- Provide a specific cosmetic regimen for acne-prone women, including a silicone-based makeup and active ingredients for treatment in cosmetics and skin care.
I recently interviewed Stanley Levy, MD, who was one of the consultants to Almay, and practices in Chapel Hill, N.C., where he has an academic niche related to skin care formulation and safety. He told me how Almay provided patch test materials to dermatologists to help identify contact dermatitis to cosmetic ingredients, and described Almay’s relationship with the dermatology field as follows: “From the outset, Almay was linked to dermatology. In 1930, a chemist and pharmacist in New York City, Al Woititz, was looking to compound cosmetics for his wife suffering from cosmetic allergies, Fannie May. He enlisted the counsel of the preeminent dermatologic expert in contact dermatitis at the time, Dr. Marion Sulzberger, to suggest ingredients to avoid. [Dr. Sulzberger was also a member of the original Dermatology News editorial advisory board.] Soon, dermatologists around New York City were recommending these formulations. This led to a product line free of the known allergens and a fledgling company trademarked as Almay. For the past 90 years, [the company] has kept a close relationship with dermatologists, well before that was the norm.”
The Almay research overseen by Dr. Levy and others contributed greatly to our understanding of the allergenicity of skin care.
Albert Kligman, MD
The turning point for the interface of dermatology with the cosmetic industry was the shift from a safety-based approach (hypoallergenic and noncomedogenic) to an emphasis on efficacy claims in the 1980s. Part of the impetus for this was the Dr. Kligman’s observation that retinoids could improve photoaging.
Dr. Kligman, a well-known dermatologist at the University of Pennsylvania, Philadelphia, showed that retinoids were an effective treatment for acne. For more about this, listen to my interview on the Dermatology Weekly podcast, with James Leyden, MD, about his work at the University of Pennsylvania with Dr. Kligman on the development of oral and topical retinoids. During Dr. Kligman’s research on acne, he noticed that wrinkles improved after treatment with tretinoin, and in 1986, he and Dr. Leyden (and several other authors) published the first article about tretinoin’s use for photoaged skin.3 This led to a double-blind study4 conducted by John J. Voorhees, MD, University of Michigan, Ann Arbor, and coauthors that showed statistically significant improvement of photoaged skin when treated with topical tretinoin. Dr. Voorhees and his group did many more studies on retinoids5,6 and photoaging7 – so many that, at one time, he was (and maybe still is) the most widely published dermatologist in the United States. These studies showed that, not only did prescription tretinoin improve the appearance of wrinkles, but so did over-the-counter retinol.8 Retinoids remain the most efficacious prescription and cosmeceutical ingredients to treat wrinkled skin.
When studies conducted by Dr. Kligman, Dr. Voorhees, and by Barbara Gilcrest, MD, 9,10 showed that retinoids improved wrinkles, a major change in the focus in the skin care industry occurred.
During the same time period, the studies on alpha hydroxy acids by Chérie Ditre, MD, Eugene Van Scott, MD, and colleages11,12; and studies by Sheldon Pinnell, MD, on Vitamin C (see part 1 of this series) all demonstrated the efficacy of cosmetic ingredients on photoaged skin. This triggered a major change in how skin care products were marketed, with an efficacy approach rather than a safety approach.
With the shift from safety (hypoallergenic and noncomedogenic issues) to efficacy claims in the 1980s, and as nondrug active ingredients like retinol were shown to have biologic effects, the lines between the Food and Drug Administration’s definition of a drug versus a cosmetic became blurred. In 1984, Dr. Kligman suggested a new classification for the ingredients that fell in the middle, proposing the term “cosmeceutical” and thus, the concept of a cosmeceutical was introduced. To this day, cosmeceutical is not an official definition and the FDA has yet to deal with it as a quasi-drug category. FDA regulations as to what constitutes a drug versus a cosmetic date back to the 1938 Food, Drug and Cosmetic Act.
Once marketing focused on efficacy, many companies made outrageous claims. During the second half of the 1980s, the FDA issued some warning letters to some companies in an effort to control these claims.
Now efficacy claims abound and we, as dermatologists, should be the experts who back up these claims with scientific data. As the cosmeceutical market has evolved and grown, consumers are bewildered by the myriad of active ingredients being promoted and the number of products in the marketplace. As dermatologic innovation has led to more efficacious active ingredients, our patients look to us as knowledgeable and credible sources of information and for recommendations about the best skin care routines for their skin issues. This is all reflected in the fact that physician-dispensed skin care is becoming the fastest growing segment in this market. It is incumbent upon dermatologists to be knowledgeable and conversant about skin care products and skin care routines, and is particularly true for those of us who sell skin care products in our offices.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Burt’s Bees, Evolus, Galderma, and Revance. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Vogue Magazine, 1967 Aug 15. “Can Great Skin be Created?”
2. https://patents.google.com/patent/US3910284.
3. Kligman AM et al. J Am Acad Dermatol. 1986 Oct;15(4 Pt 2):836-59.
4. Weiss JS et al. JAMA. 1988 Jan 22-29;259(4):527-32.
5. Goldfarb MT et al. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):645-50.
6. Ellis CN et al. J Am Acad Dermatol. 1990 Oct;23(4 Pt 1):629-37.
7. Kang S; Voorhees JJ. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S55-61.
8. Kafi R et al. Arch Dermatol. 2007 May;143(5):606-12.
9. Gilchrest BA. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):610-3.
10. Bhawan J et al. Arch Dermatol. 1991 May;127(5):666-72.
11. Griffin TD et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):196-203.
12. Ditre CM et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
This is the third in a series of columns discussing the important roles that dermatologists have played in the skin care industry. with the cosmetic industry, rather than developing their own skin care lines.
Norman Orentreich, MD
Dr. Orentreich was a successful New York City dermatologist and the first to perform hair transplants. This new technique brought him fame and notoriety and arguably made him the first “celebrity dermatologist.” (He was also a member of the original advisory board of Dermatology News, at that time Skin & Allergy News, in January 1970.) Dr. Orentreich was a seminal figure in the trend to link the cosmetic industry and dermatology. In August 1967, Vogue magazine1 published an article on him, titled “Can Great Skin be Created?” This popular article caught the attention of Leonard Lauder, of Estée Lauder, who recruited Dr. Orentreich to help create the skin care line Clinique. Clinique was intended to be a brand with a medical look that promoted its products as “allergy tested,” with packaging that has an antiseptic look and beauty counter salespeople wearing white coats.
Dr. Orentreich’s input into the development of a skin type–based skin care line was fundamental to the development of this brand. The four-question questionnaire with an iconic plastic lever that customers slide left or right instantly provided them with an assessment of their skin type at the beauty counter, with one of four skin types: Very Dry to Dry Skin (Skin Type 1), Dry Combination (Skin Type 2), Combination Oily (Skin Type 3), and Oily (Skin Type 4).
Although this skin-typing system was not scientifically accurate (there is no scientific definition of combination skin), it was reminiscent of the system developed by cosmetic company tycoon Helena Rubinstein in the 1940s that classified people into four skin types: oily, dry, combination, and sensitive. Clinique became a blockbuster skin care brand and was one of the first developed by a dermatologist – although Dr. Orentreich did not put his name on it.
In 1972, Dr. Orentreich filed a patent2 for an exfoliating pad for the skin that later became known as the “Buf-Puf.” I heard years ago that he got the idea from the machines used to buff the floors in the hospital. The buffing pad had a hole in the center where the machine attached. Dr. Orentreich purportedly thought “I wonder what they do with the cut-out centers?” He looked into this, and subsequently used the centers to create the Buf-Puf. I cannot find a reference for this, but I love this story and hope it’s true. If any readers have any knowledge of this, please let me know, so I can amend my story if it is incorrect.
Almay
Almay, an amalgamation of the founders’ names, Alfred and Fanny May Woititz, was the first hypoallergenic brand, established in 1931, and the first to provide hypoallergenic cosmetics, long before Clinique. In addition, the company was the first skin care brand to become available by prescription only (as it was initially), fully disclose all individual ingredients in its products (well before this became mandatory in 1976), provide totally fragrance-free products, develop a hypoallergenic fragrance – and provide patch tests and other materials to physicians to identify contact allergens.
Over 90 years, the company was also the first among skin care brands to do the following:
- Provide custom formulations to individuals proven to be allergic to a specific ingredient, through their physicians.
- Perform a full range of premarket safety testing on all products for allergy and irritation, and test all its products for comedogenicity.
- Formulate cosmetics for use around the eye area (eye shadows and eyeliners) specifically for contact lens wearers.
- Formulate hypoallergenic regimens for specific skin types in the mass market.
- Provide a specific cosmetic regimen for acne-prone women, including a silicone-based makeup and active ingredients for treatment in cosmetics and skin care.
I recently interviewed Stanley Levy, MD, who was one of the consultants to Almay, and practices in Chapel Hill, N.C., where he has an academic niche related to skin care formulation and safety. He told me how Almay provided patch test materials to dermatologists to help identify contact dermatitis to cosmetic ingredients, and described Almay’s relationship with the dermatology field as follows: “From the outset, Almay was linked to dermatology. In 1930, a chemist and pharmacist in New York City, Al Woititz, was looking to compound cosmetics for his wife suffering from cosmetic allergies, Fannie May. He enlisted the counsel of the preeminent dermatologic expert in contact dermatitis at the time, Dr. Marion Sulzberger, to suggest ingredients to avoid. [Dr. Sulzberger was also a member of the original Dermatology News editorial advisory board.] Soon, dermatologists around New York City were recommending these formulations. This led to a product line free of the known allergens and a fledgling company trademarked as Almay. For the past 90 years, [the company] has kept a close relationship with dermatologists, well before that was the norm.”
The Almay research overseen by Dr. Levy and others contributed greatly to our understanding of the allergenicity of skin care.
Albert Kligman, MD
The turning point for the interface of dermatology with the cosmetic industry was the shift from a safety-based approach (hypoallergenic and noncomedogenic) to an emphasis on efficacy claims in the 1980s. Part of the impetus for this was the Dr. Kligman’s observation that retinoids could improve photoaging.
Dr. Kligman, a well-known dermatologist at the University of Pennsylvania, Philadelphia, showed that retinoids were an effective treatment for acne. For more about this, listen to my interview on the Dermatology Weekly podcast, with James Leyden, MD, about his work at the University of Pennsylvania with Dr. Kligman on the development of oral and topical retinoids. During Dr. Kligman’s research on acne, he noticed that wrinkles improved after treatment with tretinoin, and in 1986, he and Dr. Leyden (and several other authors) published the first article about tretinoin’s use for photoaged skin.3 This led to a double-blind study4 conducted by John J. Voorhees, MD, University of Michigan, Ann Arbor, and coauthors that showed statistically significant improvement of photoaged skin when treated with topical tretinoin. Dr. Voorhees and his group did many more studies on retinoids5,6 and photoaging7 – so many that, at one time, he was (and maybe still is) the most widely published dermatologist in the United States. These studies showed that, not only did prescription tretinoin improve the appearance of wrinkles, but so did over-the-counter retinol.8 Retinoids remain the most efficacious prescription and cosmeceutical ingredients to treat wrinkled skin.
When studies conducted by Dr. Kligman, Dr. Voorhees, and by Barbara Gilcrest, MD, 9,10 showed that retinoids improved wrinkles, a major change in the focus in the skin care industry occurred.
During the same time period, the studies on alpha hydroxy acids by Chérie Ditre, MD, Eugene Van Scott, MD, and colleages11,12; and studies by Sheldon Pinnell, MD, on Vitamin C (see part 1 of this series) all demonstrated the efficacy of cosmetic ingredients on photoaged skin. This triggered a major change in how skin care products were marketed, with an efficacy approach rather than a safety approach.
With the shift from safety (hypoallergenic and noncomedogenic issues) to efficacy claims in the 1980s, and as nondrug active ingredients like retinol were shown to have biologic effects, the lines between the Food and Drug Administration’s definition of a drug versus a cosmetic became blurred. In 1984, Dr. Kligman suggested a new classification for the ingredients that fell in the middle, proposing the term “cosmeceutical” and thus, the concept of a cosmeceutical was introduced. To this day, cosmeceutical is not an official definition and the FDA has yet to deal with it as a quasi-drug category. FDA regulations as to what constitutes a drug versus a cosmetic date back to the 1938 Food, Drug and Cosmetic Act.
Once marketing focused on efficacy, many companies made outrageous claims. During the second half of the 1980s, the FDA issued some warning letters to some companies in an effort to control these claims.
Now efficacy claims abound and we, as dermatologists, should be the experts who back up these claims with scientific data. As the cosmeceutical market has evolved and grown, consumers are bewildered by the myriad of active ingredients being promoted and the number of products in the marketplace. As dermatologic innovation has led to more efficacious active ingredients, our patients look to us as knowledgeable and credible sources of information and for recommendations about the best skin care routines for their skin issues. This is all reflected in the fact that physician-dispensed skin care is becoming the fastest growing segment in this market. It is incumbent upon dermatologists to be knowledgeable and conversant about skin care products and skin care routines, and is particularly true for those of us who sell skin care products in our offices.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Burt’s Bees, Evolus, Galderma, and Revance. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
1. Vogue Magazine, 1967 Aug 15. “Can Great Skin be Created?”
2. https://patents.google.com/patent/US3910284.
3. Kligman AM et al. J Am Acad Dermatol. 1986 Oct;15(4 Pt 2):836-59.
4. Weiss JS et al. JAMA. 1988 Jan 22-29;259(4):527-32.
5. Goldfarb MT et al. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):645-50.
6. Ellis CN et al. J Am Acad Dermatol. 1990 Oct;23(4 Pt 1):629-37.
7. Kang S; Voorhees JJ. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S55-61.
8. Kafi R et al. Arch Dermatol. 2007 May;143(5):606-12.
9. Gilchrest BA. J Am Acad Dermatol. 1989 Sep;21(3 Pt 2):610-3.
10. Bhawan J et al. Arch Dermatol. 1991 May;127(5):666-72.
11. Griffin TD et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):196-203.
12. Ditre CM et al. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
Treating the jowl fat overhang with deoxycholic acid
Rejuvenation of the lower face often involves treatment of the submentum and the jowls. Energy-based devices such as lasers, radiofrequency, radiofrequency microneedling, CoolSculpting, and ultrasound have been used in the tightening of the neck and jowls.
However, the only noninvasive injectable treatment approved for the reduction of submental fat is deoxycholic acid (Kybella). The mechanism of action of deoxycholic acid has been documented as adipocyte lysis, followed by a local tissue response with neutrophil infiltration, septal thickening, neocollagenesis, and neovascularization within the subcutaneous layer, with no adverse changes in the dermis or epidermis. This treatment, which has a dose-dependent response, is highly effective for submental fat reduction and jaw contouring.
In my practice, I have found that multiple consecutive treatments with deoxycholic acid (an off-label use) are effective in permanently reducing the jowl overhang with minimal adverse effects.
Jowl fat is a common cause of sagging of the jowls, and there are few alternatives to treatment with surgery or liposuction. Jowl overhang results from multiple factors related to aging, including skeletal resorption, subcutaneous atrophy, superior and inferior fat pad compartment displacement, or mandibular septum dehiscence, which allows for the accumulation of fat pockets to migrate into the neck.
A prospective study published earlier this year describes results in 66 adults with excess jowl fat, who were treated with 2 mg/cm2 of deoxycholic acid. Injections were done in patients with “pinchable fat on the jawline” and “relatively” minimal skin laxity of 0.2 mL spaced approximately 1 cm apart or 0.1 mL spaced 0.5 cm-0.75 cm apart; the mean injection volume was 0.8 mL. After 6 months, 98% of the patients experienced improvement with a mean of 1.8 treatments. Common injection site adverse events included edema, numbness, tenderness, and bruising.
In my experience, injection volumes from 1.0 mL to 1.5 mL of deoxycholic acid can be used in each jowl with minimal adverse events if proper landmarks are followed. It is crucial that the correct patient is selected (one with minimal skin laxity), and that during injection, the fat and skin are pinched away from the underlying musculature and neurovascular structures to avoid injection near the marginal mandibular nerve. Volumes less than 1.0 mL have minimal visible improvements and will require more than 3-4 treatment sessions for optimal results.
. I often see a marked improvement in patients who present prominent marionette lines who have been unhappy with fillers in the lower face. Often, the marionette lines are a result of significant overhang from jowl fat and hyaluronic acid fillers are a temporary and often unsatisfactory treatment option. The use of deoxycholic acid in the treatment of the jowl fat is a highly effective option to minimize the appearance of marionette lines caused by displaced fat pockets in the aging lower face.
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 [email protected] . They had no relevant disclosures.
Rejuvenation of the lower face often involves treatment of the submentum and the jowls. Energy-based devices such as lasers, radiofrequency, radiofrequency microneedling, CoolSculpting, and ultrasound have been used in the tightening of the neck and jowls.
However, the only noninvasive injectable treatment approved for the reduction of submental fat is deoxycholic acid (Kybella). The mechanism of action of deoxycholic acid has been documented as adipocyte lysis, followed by a local tissue response with neutrophil infiltration, septal thickening, neocollagenesis, and neovascularization within the subcutaneous layer, with no adverse changes in the dermis or epidermis. This treatment, which has a dose-dependent response, is highly effective for submental fat reduction and jaw contouring.
In my practice, I have found that multiple consecutive treatments with deoxycholic acid (an off-label use) are effective in permanently reducing the jowl overhang with minimal adverse effects.
Jowl fat is a common cause of sagging of the jowls, and there are few alternatives to treatment with surgery or liposuction. Jowl overhang results from multiple factors related to aging, including skeletal resorption, subcutaneous atrophy, superior and inferior fat pad compartment displacement, or mandibular septum dehiscence, which allows for the accumulation of fat pockets to migrate into the neck.
A prospective study published earlier this year describes results in 66 adults with excess jowl fat, who were treated with 2 mg/cm2 of deoxycholic acid. Injections were done in patients with “pinchable fat on the jawline” and “relatively” minimal skin laxity of 0.2 mL spaced approximately 1 cm apart or 0.1 mL spaced 0.5 cm-0.75 cm apart; the mean injection volume was 0.8 mL. After 6 months, 98% of the patients experienced improvement with a mean of 1.8 treatments. Common injection site adverse events included edema, numbness, tenderness, and bruising.
In my experience, injection volumes from 1.0 mL to 1.5 mL of deoxycholic acid can be used in each jowl with minimal adverse events if proper landmarks are followed. It is crucial that the correct patient is selected (one with minimal skin laxity), and that during injection, the fat and skin are pinched away from the underlying musculature and neurovascular structures to avoid injection near the marginal mandibular nerve. Volumes less than 1.0 mL have minimal visible improvements and will require more than 3-4 treatment sessions for optimal results.
. I often see a marked improvement in patients who present prominent marionette lines who have been unhappy with fillers in the lower face. Often, the marionette lines are a result of significant overhang from jowl fat and hyaluronic acid fillers are a temporary and often unsatisfactory treatment option. The use of deoxycholic acid in the treatment of the jowl fat is a highly effective option to minimize the appearance of marionette lines caused by displaced fat pockets in the aging lower face.
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 [email protected] . They had no relevant disclosures.
Rejuvenation of the lower face often involves treatment of the submentum and the jowls. Energy-based devices such as lasers, radiofrequency, radiofrequency microneedling, CoolSculpting, and ultrasound have been used in the tightening of the neck and jowls.
However, the only noninvasive injectable treatment approved for the reduction of submental fat is deoxycholic acid (Kybella). The mechanism of action of deoxycholic acid has been documented as adipocyte lysis, followed by a local tissue response with neutrophil infiltration, septal thickening, neocollagenesis, and neovascularization within the subcutaneous layer, with no adverse changes in the dermis or epidermis. This treatment, which has a dose-dependent response, is highly effective for submental fat reduction and jaw contouring.
In my practice, I have found that multiple consecutive treatments with deoxycholic acid (an off-label use) are effective in permanently reducing the jowl overhang with minimal adverse effects.
Jowl fat is a common cause of sagging of the jowls, and there are few alternatives to treatment with surgery or liposuction. Jowl overhang results from multiple factors related to aging, including skeletal resorption, subcutaneous atrophy, superior and inferior fat pad compartment displacement, or mandibular septum dehiscence, which allows for the accumulation of fat pockets to migrate into the neck.
A prospective study published earlier this year describes results in 66 adults with excess jowl fat, who were treated with 2 mg/cm2 of deoxycholic acid. Injections were done in patients with “pinchable fat on the jawline” and “relatively” minimal skin laxity of 0.2 mL spaced approximately 1 cm apart or 0.1 mL spaced 0.5 cm-0.75 cm apart; the mean injection volume was 0.8 mL. After 6 months, 98% of the patients experienced improvement with a mean of 1.8 treatments. Common injection site adverse events included edema, numbness, tenderness, and bruising.
In my experience, injection volumes from 1.0 mL to 1.5 mL of deoxycholic acid can be used in each jowl with minimal adverse events if proper landmarks are followed. It is crucial that the correct patient is selected (one with minimal skin laxity), and that during injection, the fat and skin are pinched away from the underlying musculature and neurovascular structures to avoid injection near the marginal mandibular nerve. Volumes less than 1.0 mL have minimal visible improvements and will require more than 3-4 treatment sessions for optimal results.
. I often see a marked improvement in patients who present prominent marionette lines who have been unhappy with fillers in the lower face. Often, the marionette lines are a result of significant overhang from jowl fat and hyaluronic acid fillers are a temporary and often unsatisfactory treatment option. The use of deoxycholic acid in the treatment of the jowl fat is a highly effective option to minimize the appearance of marionette lines caused by displaced fat pockets in the aging lower face.
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 [email protected] . They had no relevant disclosures.
New technologies show promise for treating pigmented lesions
carry a higher risk for postinflammatory hyperpigmentation than intense pulsed light or the long-pulsed laser, according to Mathew M. Avram, MD, JD.
For treating melanosomes with selective photothermolysis, some of the peak wavelengths include 532 nm, 694 nm, 755 nm, and 1064 nm, Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, said during the virtual annual Masters of Aesthetics Symposium. “The ideal target is fair skin with a dark, pigmented lesion,” he said. “That way you’re going to get energy focused to the melanin that’s in the lesion itself.”
Q-switched and picosecond lasers are effective for pigmented lesions. These employ as much energy as the city of Boston for 20-30 billionths of a second, or 750 picoseconds. “This raises the temperature to 1,000° C in that time, which produces the characteristic epidermal whitening,” he said. “This targets pigment cells only, whether it’s exogenous or endogenous pigment.”
Benign pigmented lesions amenable to the Q-switched nanosecond and picosecond laser include lentigines and nevus of Ota/Ito. The mechanism of action for clinical lightening is fragmentation and release of melanin-laden cells and the gradual uptake and removal of fragments by activated macrophages into lymphatic vessels. “For effective results, do not blindly memorize settings or replicate recommended settings from a colleague or a device manufacturer,” advised Dr. Avram, who practiced law prior to becoming a physician. “Some lasers are not externally calibrated, so what you have to do is pay attention to the laser endpoint, which in this case is epidermal whitening. Tissue ‘splatter’ is an unsafe endpoint and may lead to scarring. Safe and unsafe laser endpoints and close clinical observation are the best means to avoid complications and get the best results for your patients. The key finding is the endpoint, not the energy settings.”
Pigmented lesions that should not be treated with a laser include atypical nevi, lentigo maligna, and other forms of melanoma. “When in doubt, perform a biopsy,” he said. “Regardless of who referred the case, you are liable if you treat a melanoma with a laser. This is not only misdiagnosis but it probably delays diagnosis as well. If you cannot recognize basis pigmented lesion morphology, do not treat pigmented lesions. At some point, it’s going to catch up with you.”
Patients with more pigment to their skin face a higher risk for postinflammatory hyperpigmentation, Dr. Avram continued. While longer pulsed lasers produce less hyperpigmentation, they’re also less effective at getting rid of lesions. “You can combine a long-pulsed laser with fractional resurfacing or IPL [intense pulsed light] to optimize improvement,” he said. “If you don’t have two lasers to use, you can just use a longer-pulsed laser. The desired treatment endpoint for this approach is an ashen gray appearance.” Options include a 532-nm Nd:YAG laser with or without cooling, a 595-nm pulsed dye laser without cooling, and a 755-nm alexandrite laser without cooling.
One advance in the treatment of seborrheic keratoses is Nano-Pulse Stimulation (NPS), a novel technology being developed by Pulse Biosciences. With this approach, nanosecond electrical energy pulses cause internal organelle disruption, which leads to regulated cell death. “The cell-specific effect is nonthermal, as a typical nano-pulse delivers 0.1 joules of energy distributed in a volume of tissue,” Dr. Avram said. Early human studies established safe doses and validation of mechanism hypothesis for benign-lesion efficacy. “What you have are tiny nanopores that allow calcium ions to flow into the cell,” he explained. “The nanopores in the endoplasmic reticulum allow calcium ions to flow out of the endoplasmic reticulum, stressing it. These nanopores in the mitochondria disrupt the ability to generate energy, and the cell dies.”
Histology has revealed that within days the procedure causes regulated cell death with no thermal effects. The ability of NPS energy to clear seborrheic keratoses (SK) was confirmed in a study of 58 subjects who had 174 SK lesions treated. The majority of SKs (82%) were rated as clear or mostly clear 106 days post treatment. All results reflected a single treatment session.
Another novel treatment, “cryomodulation,” a technology being developed by R. Rox Anderson, MD, Dieter Manstein, MD, PhD, and Henry Chan, MD, PhD, expresses cold-induced change to the skin as a way to pause melanin production. “You get melanin production paused but melanocyte function is preserved,” Dr. Avram explained. “There is a normal epidermal barrier and no persistent inflammatory response, so there’s no hyperpigmentation.” He characterized it as an ease-of-use clinical procedure for treating benign lesions in all skin types. A mask is applied to confine freezing to the desired treatment area, and hydrated gauze is used to help facilitate ice crystal propagation. A prototype of the device features a parameter selection based on lesion type, anatomical location, and skin type. “It uses between 107 and 166 kJ/m2 of extracted energy, and you take photos at baseline and follow-up,” he said. “You get 2-3 days of redness, darkening, and swelling. It’s well tolerated, with minimal discomfort. There’s no long-term dyschromia. This is nice, because patients have little, if any, downtime.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, and Soliton. He also reported having ownership and/or shareholder interest in Cytrellis.
carry a higher risk for postinflammatory hyperpigmentation than intense pulsed light or the long-pulsed laser, according to Mathew M. Avram, MD, JD.
For treating melanosomes with selective photothermolysis, some of the peak wavelengths include 532 nm, 694 nm, 755 nm, and 1064 nm, Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, said during the virtual annual Masters of Aesthetics Symposium. “The ideal target is fair skin with a dark, pigmented lesion,” he said. “That way you’re going to get energy focused to the melanin that’s in the lesion itself.”
Q-switched and picosecond lasers are effective for pigmented lesions. These employ as much energy as the city of Boston for 20-30 billionths of a second, or 750 picoseconds. “This raises the temperature to 1,000° C in that time, which produces the characteristic epidermal whitening,” he said. “This targets pigment cells only, whether it’s exogenous or endogenous pigment.”
Benign pigmented lesions amenable to the Q-switched nanosecond and picosecond laser include lentigines and nevus of Ota/Ito. The mechanism of action for clinical lightening is fragmentation and release of melanin-laden cells and the gradual uptake and removal of fragments by activated macrophages into lymphatic vessels. “For effective results, do not blindly memorize settings or replicate recommended settings from a colleague or a device manufacturer,” advised Dr. Avram, who practiced law prior to becoming a physician. “Some lasers are not externally calibrated, so what you have to do is pay attention to the laser endpoint, which in this case is epidermal whitening. Tissue ‘splatter’ is an unsafe endpoint and may lead to scarring. Safe and unsafe laser endpoints and close clinical observation are the best means to avoid complications and get the best results for your patients. The key finding is the endpoint, not the energy settings.”
Pigmented lesions that should not be treated with a laser include atypical nevi, lentigo maligna, and other forms of melanoma. “When in doubt, perform a biopsy,” he said. “Regardless of who referred the case, you are liable if you treat a melanoma with a laser. This is not only misdiagnosis but it probably delays diagnosis as well. If you cannot recognize basis pigmented lesion morphology, do not treat pigmented lesions. At some point, it’s going to catch up with you.”
Patients with more pigment to their skin face a higher risk for postinflammatory hyperpigmentation, Dr. Avram continued. While longer pulsed lasers produce less hyperpigmentation, they’re also less effective at getting rid of lesions. “You can combine a long-pulsed laser with fractional resurfacing or IPL [intense pulsed light] to optimize improvement,” he said. “If you don’t have two lasers to use, you can just use a longer-pulsed laser. The desired treatment endpoint for this approach is an ashen gray appearance.” Options include a 532-nm Nd:YAG laser with or without cooling, a 595-nm pulsed dye laser without cooling, and a 755-nm alexandrite laser without cooling.
One advance in the treatment of seborrheic keratoses is Nano-Pulse Stimulation (NPS), a novel technology being developed by Pulse Biosciences. With this approach, nanosecond electrical energy pulses cause internal organelle disruption, which leads to regulated cell death. “The cell-specific effect is nonthermal, as a typical nano-pulse delivers 0.1 joules of energy distributed in a volume of tissue,” Dr. Avram said. Early human studies established safe doses and validation of mechanism hypothesis for benign-lesion efficacy. “What you have are tiny nanopores that allow calcium ions to flow into the cell,” he explained. “The nanopores in the endoplasmic reticulum allow calcium ions to flow out of the endoplasmic reticulum, stressing it. These nanopores in the mitochondria disrupt the ability to generate energy, and the cell dies.”
Histology has revealed that within days the procedure causes regulated cell death with no thermal effects. The ability of NPS energy to clear seborrheic keratoses (SK) was confirmed in a study of 58 subjects who had 174 SK lesions treated. The majority of SKs (82%) were rated as clear or mostly clear 106 days post treatment. All results reflected a single treatment session.
Another novel treatment, “cryomodulation,” a technology being developed by R. Rox Anderson, MD, Dieter Manstein, MD, PhD, and Henry Chan, MD, PhD, expresses cold-induced change to the skin as a way to pause melanin production. “You get melanin production paused but melanocyte function is preserved,” Dr. Avram explained. “There is a normal epidermal barrier and no persistent inflammatory response, so there’s no hyperpigmentation.” He characterized it as an ease-of-use clinical procedure for treating benign lesions in all skin types. A mask is applied to confine freezing to the desired treatment area, and hydrated gauze is used to help facilitate ice crystal propagation. A prototype of the device features a parameter selection based on lesion type, anatomical location, and skin type. “It uses between 107 and 166 kJ/m2 of extracted energy, and you take photos at baseline and follow-up,” he said. “You get 2-3 days of redness, darkening, and swelling. It’s well tolerated, with minimal discomfort. There’s no long-term dyschromia. This is nice, because patients have little, if any, downtime.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, and Soliton. He also reported having ownership and/or shareholder interest in Cytrellis.
carry a higher risk for postinflammatory hyperpigmentation than intense pulsed light or the long-pulsed laser, according to Mathew M. Avram, MD, JD.
For treating melanosomes with selective photothermolysis, some of the peak wavelengths include 532 nm, 694 nm, 755 nm, and 1064 nm, Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston, said during the virtual annual Masters of Aesthetics Symposium. “The ideal target is fair skin with a dark, pigmented lesion,” he said. “That way you’re going to get energy focused to the melanin that’s in the lesion itself.”
Q-switched and picosecond lasers are effective for pigmented lesions. These employ as much energy as the city of Boston for 20-30 billionths of a second, or 750 picoseconds. “This raises the temperature to 1,000° C in that time, which produces the characteristic epidermal whitening,” he said. “This targets pigment cells only, whether it’s exogenous or endogenous pigment.”
Benign pigmented lesions amenable to the Q-switched nanosecond and picosecond laser include lentigines and nevus of Ota/Ito. The mechanism of action for clinical lightening is fragmentation and release of melanin-laden cells and the gradual uptake and removal of fragments by activated macrophages into lymphatic vessels. “For effective results, do not blindly memorize settings or replicate recommended settings from a colleague or a device manufacturer,” advised Dr. Avram, who practiced law prior to becoming a physician. “Some lasers are not externally calibrated, so what you have to do is pay attention to the laser endpoint, which in this case is epidermal whitening. Tissue ‘splatter’ is an unsafe endpoint and may lead to scarring. Safe and unsafe laser endpoints and close clinical observation are the best means to avoid complications and get the best results for your patients. The key finding is the endpoint, not the energy settings.”
Pigmented lesions that should not be treated with a laser include atypical nevi, lentigo maligna, and other forms of melanoma. “When in doubt, perform a biopsy,” he said. “Regardless of who referred the case, you are liable if you treat a melanoma with a laser. This is not only misdiagnosis but it probably delays diagnosis as well. If you cannot recognize basis pigmented lesion morphology, do not treat pigmented lesions. At some point, it’s going to catch up with you.”
Patients with more pigment to their skin face a higher risk for postinflammatory hyperpigmentation, Dr. Avram continued. While longer pulsed lasers produce less hyperpigmentation, they’re also less effective at getting rid of lesions. “You can combine a long-pulsed laser with fractional resurfacing or IPL [intense pulsed light] to optimize improvement,” he said. “If you don’t have two lasers to use, you can just use a longer-pulsed laser. The desired treatment endpoint for this approach is an ashen gray appearance.” Options include a 532-nm Nd:YAG laser with or without cooling, a 595-nm pulsed dye laser without cooling, and a 755-nm alexandrite laser without cooling.
One advance in the treatment of seborrheic keratoses is Nano-Pulse Stimulation (NPS), a novel technology being developed by Pulse Biosciences. With this approach, nanosecond electrical energy pulses cause internal organelle disruption, which leads to regulated cell death. “The cell-specific effect is nonthermal, as a typical nano-pulse delivers 0.1 joules of energy distributed in a volume of tissue,” Dr. Avram said. Early human studies established safe doses and validation of mechanism hypothesis for benign-lesion efficacy. “What you have are tiny nanopores that allow calcium ions to flow into the cell,” he explained. “The nanopores in the endoplasmic reticulum allow calcium ions to flow out of the endoplasmic reticulum, stressing it. These nanopores in the mitochondria disrupt the ability to generate energy, and the cell dies.”
Histology has revealed that within days the procedure causes regulated cell death with no thermal effects. The ability of NPS energy to clear seborrheic keratoses (SK) was confirmed in a study of 58 subjects who had 174 SK lesions treated. The majority of SKs (82%) were rated as clear or mostly clear 106 days post treatment. All results reflected a single treatment session.
Another novel treatment, “cryomodulation,” a technology being developed by R. Rox Anderson, MD, Dieter Manstein, MD, PhD, and Henry Chan, MD, PhD, expresses cold-induced change to the skin as a way to pause melanin production. “You get melanin production paused but melanocyte function is preserved,” Dr. Avram explained. “There is a normal epidermal barrier and no persistent inflammatory response, so there’s no hyperpigmentation.” He characterized it as an ease-of-use clinical procedure for treating benign lesions in all skin types. A mask is applied to confine freezing to the desired treatment area, and hydrated gauze is used to help facilitate ice crystal propagation. A prototype of the device features a parameter selection based on lesion type, anatomical location, and skin type. “It uses between 107 and 166 kJ/m2 of extracted energy, and you take photos at baseline and follow-up,” he said. “You get 2-3 days of redness, darkening, and swelling. It’s well tolerated, with minimal discomfort. There’s no long-term dyschromia. This is nice, because patients have little, if any, downtime.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, and Soliton. He also reported having ownership and/or shareholder interest in Cytrellis.
FROM MOA 2020
Expert offers tips for combining lasers and injectables on the same day
While if it involves the same area.
“Swelling from the laser can potentially make the toxin migrate and cause ptosis,” Arisa E. Ortiz, MD, said at the virtual annual Masters of Aesthetics Symposium. “Even though this is temporary, your patient’s not going to be very happy with you. I would separate these at least 1 day apart, and then you should be OK.”
When using a filler on the same day as a laser treatment, Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego, performs the laser procedure after injecting the filler, “because you may get some swelling, which can distort your need for filler,” she said. “I like to do the filler first to make sure I can assess how much volume loss they have. Then I’ll do the laser procedure right after.”
Another general rule of thumb is that, when combining lasers on the same day, consider lowering the device settings, “because it’s going to be a more aggressive treatment when you’re combining various laser procedures,” she said. “Treat vascular lesions first to not exacerbate nonspecific erythema. Then treat pigment, then resurfacing, followed by liquid nitrogen if needed to treat seborrheic keratoses.”
For periorbital rejuvenation, Dr. Ortiz likes to use a neurotoxin 1 week before performing the laser-resurfacing or skin-tightening procedure, followed by injection of a filler. “This augments your results,” she said. “Studies have shown that, if you start with a neuromodulator, you can get more improvement with your resurfacing procedure,” she said. “That makes sense, because you’re not contracting the muscle while you’re healing from the laser, so you get more effective collagen remodeling.”
When using a neuromodulator for dynamic periorbital rhytides, place it superficially to avoid bruising and stay superior to the maxillary prominence to avoid the zygomaticus major “so you don’t get a droopy smile,” she said. “The approved dosing is 24 units, 12 on each side. Less may be required for younger patients and more for more severe rhytides.”
For static rhytides, fractional resurfacing procedures will provide a more modest result with less downtime, while fully ablative laser resurfacing procedures will provide more dramatic improvement with more downtime. “You’re really going to tailor your treatment to what the patient is looking for,” Dr. Ortiz said. “If you use a fractional device you may need multiple treatments. Using a corneal shield when you’re resurfacing within the periorbital rim is a must, so you need to know how to place these if you’re going to be resurfacing in that area.”
For anesthesia, Dr. Ortiz likes to use injectable lidocaine, “because if you use a topical it can creep into the eye, and then you get a chemical corneal abrasion. This resolves after a few days but it’s really painful and your patient won’t be very happy.”
For tear troughs, use a hyaluronic acid filler with a low G prime. “If you use a thicker filler it can look lumpy or too full,” she said. While some clinicians use a needle to administer the filler, Dr. Ortiz prefers to use a blunt-tipped cannula. “It’s less painful and there’s less risk of bruising or swelling,” she said. “There’s also less risk of cannulizing a vessel. This is not zero risk. It’s been shown that the 27-gauge can actually cannulize the vessel, so it shouldn’t give you a false sense of security, but there is less risk, compared with using a needle. You can use the cannula to thread. If you’re using a needle you can inject a bolus and then massage it in, or you can use the microdroplet technique.”
With the cannula technique, bruising or swelling can occur even in the most experienced hands, “so make sure your patients don’t have an important event coming up,” Dr. Ortiz said. “With filler, not only do you improve the volume loss, but sometimes you improve the dark circles. I tend to see this more in lighter-skinned patients. In darker-skinned patients, the dark circles can be caused by racial pigmentation. That’s hard to fix, so I never promise that we can improve dark circles, but sometimes it does improve.”
For dynamic perioral rhytides, Dr. Ortiz generally treats with a neuromodulator 1 week in advance of laser resurfacing, followed by a filler for any etched-in lines. Use of a neuromodulator in the perioral region of musicians or singers is contraindicated “because it can affect their phonation,” she said. “Also, older patients might complain that it’s difficult for them to pucker their lips when they’re putting on a lip liner or lipstick. There are four injection sites on the upper lip and two on the lower lip. I do 1 unit at each injection site, with a max of 6-8 units. Any more than that and they’ll have difficulty puckering.”
Two main options for treating submental fullness include cryolipolysis or deoxycholic acid. “If you have a lot of volume, you want to use cryolipolysis,” Dr. Ortiz said. “The general rule is, if it fits in the cup [of the applicator], hook them up.” Use deoxycholic acid for areas of smaller volume, or to fine-tune, she added.
For platysmal bands, Dr. Ortiz favors injecting 2 units of botulinum toxin at three to four sites along the band. She pulls away and injects superficially and limits the treatment dose to 40 units in one session “because excessive doses can cause dysphagia,” she said. “If they need additional units, I’ll have them come back in 2 weeks.”
The Nefertiti lift combines the treatment of the platysma with the insertion point of the platysma along the jawline. Treatment of the patient along the lateral jawline with 2 units of botulinum toxin every centimeter or so can actually improve the definition of the jawline, “because your platysma is pulling down on your lower face,” Dr. Ortiz explained. “So, if you relax that, it can help to define the jawline. By treating the platysma, you can also prevent or soften the horizontal bands that occur across the neck.”
For necklace creases, she likes to inject 1-2 units of a low-HA filler along the crease – evenly spaced all along. “I’ll dilute it even further with 0.5 cc of lidocaine with epinephrine,” she said. “Then you can do serial punctures or you can thread along that line.”
For treating static rhytides on the neck, laser-resurfacing procedures work best, but at low settings. “Because there are fewer adnexal structures, the neck is at increased risk for scarring,” Dr. Ortiz said. “You want to use a lower fluence because your neck skin is thin. Your fluence determines your depth with resurfacing. Most importantly, use a lower density for a more conservative setting”
Options for treating poikiloderma of Civatte include the vascular laser, an IPL [intense pulsed light device], or a 1927-nm thulium laser. To avoid footprinting, or a “chicken wire” appearance to the treated area, Dr. Ortiz recommends using a large spot size with the pulsed dye laser or the IPL.
She concluded her presentation by underscoring the importance of communicating realistic expectations with patients. “There is some delayed gratification here,” she said. “For procedures that take time to see results, consider adding another procedure that will give them immediate results.”
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOA.
While if it involves the same area.
“Swelling from the laser can potentially make the toxin migrate and cause ptosis,” Arisa E. Ortiz, MD, said at the virtual annual Masters of Aesthetics Symposium. “Even though this is temporary, your patient’s not going to be very happy with you. I would separate these at least 1 day apart, and then you should be OK.”
When using a filler on the same day as a laser treatment, Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego, performs the laser procedure after injecting the filler, “because you may get some swelling, which can distort your need for filler,” she said. “I like to do the filler first to make sure I can assess how much volume loss they have. Then I’ll do the laser procedure right after.”
Another general rule of thumb is that, when combining lasers on the same day, consider lowering the device settings, “because it’s going to be a more aggressive treatment when you’re combining various laser procedures,” she said. “Treat vascular lesions first to not exacerbate nonspecific erythema. Then treat pigment, then resurfacing, followed by liquid nitrogen if needed to treat seborrheic keratoses.”
For periorbital rejuvenation, Dr. Ortiz likes to use a neurotoxin 1 week before performing the laser-resurfacing or skin-tightening procedure, followed by injection of a filler. “This augments your results,” she said. “Studies have shown that, if you start with a neuromodulator, you can get more improvement with your resurfacing procedure,” she said. “That makes sense, because you’re not contracting the muscle while you’re healing from the laser, so you get more effective collagen remodeling.”
When using a neuromodulator for dynamic periorbital rhytides, place it superficially to avoid bruising and stay superior to the maxillary prominence to avoid the zygomaticus major “so you don’t get a droopy smile,” she said. “The approved dosing is 24 units, 12 on each side. Less may be required for younger patients and more for more severe rhytides.”
For static rhytides, fractional resurfacing procedures will provide a more modest result with less downtime, while fully ablative laser resurfacing procedures will provide more dramatic improvement with more downtime. “You’re really going to tailor your treatment to what the patient is looking for,” Dr. Ortiz said. “If you use a fractional device you may need multiple treatments. Using a corneal shield when you’re resurfacing within the periorbital rim is a must, so you need to know how to place these if you’re going to be resurfacing in that area.”
For anesthesia, Dr. Ortiz likes to use injectable lidocaine, “because if you use a topical it can creep into the eye, and then you get a chemical corneal abrasion. This resolves after a few days but it’s really painful and your patient won’t be very happy.”
For tear troughs, use a hyaluronic acid filler with a low G prime. “If you use a thicker filler it can look lumpy or too full,” she said. While some clinicians use a needle to administer the filler, Dr. Ortiz prefers to use a blunt-tipped cannula. “It’s less painful and there’s less risk of bruising or swelling,” she said. “There’s also less risk of cannulizing a vessel. This is not zero risk. It’s been shown that the 27-gauge can actually cannulize the vessel, so it shouldn’t give you a false sense of security, but there is less risk, compared with using a needle. You can use the cannula to thread. If you’re using a needle you can inject a bolus and then massage it in, or you can use the microdroplet technique.”
With the cannula technique, bruising or swelling can occur even in the most experienced hands, “so make sure your patients don’t have an important event coming up,” Dr. Ortiz said. “With filler, not only do you improve the volume loss, but sometimes you improve the dark circles. I tend to see this more in lighter-skinned patients. In darker-skinned patients, the dark circles can be caused by racial pigmentation. That’s hard to fix, so I never promise that we can improve dark circles, but sometimes it does improve.”
For dynamic perioral rhytides, Dr. Ortiz generally treats with a neuromodulator 1 week in advance of laser resurfacing, followed by a filler for any etched-in lines. Use of a neuromodulator in the perioral region of musicians or singers is contraindicated “because it can affect their phonation,” she said. “Also, older patients might complain that it’s difficult for them to pucker their lips when they’re putting on a lip liner or lipstick. There are four injection sites on the upper lip and two on the lower lip. I do 1 unit at each injection site, with a max of 6-8 units. Any more than that and they’ll have difficulty puckering.”
Two main options for treating submental fullness include cryolipolysis or deoxycholic acid. “If you have a lot of volume, you want to use cryolipolysis,” Dr. Ortiz said. “The general rule is, if it fits in the cup [of the applicator], hook them up.” Use deoxycholic acid for areas of smaller volume, or to fine-tune, she added.
For platysmal bands, Dr. Ortiz favors injecting 2 units of botulinum toxin at three to four sites along the band. She pulls away and injects superficially and limits the treatment dose to 40 units in one session “because excessive doses can cause dysphagia,” she said. “If they need additional units, I’ll have them come back in 2 weeks.”
The Nefertiti lift combines the treatment of the platysma with the insertion point of the platysma along the jawline. Treatment of the patient along the lateral jawline with 2 units of botulinum toxin every centimeter or so can actually improve the definition of the jawline, “because your platysma is pulling down on your lower face,” Dr. Ortiz explained. “So, if you relax that, it can help to define the jawline. By treating the platysma, you can also prevent or soften the horizontal bands that occur across the neck.”
For necklace creases, she likes to inject 1-2 units of a low-HA filler along the crease – evenly spaced all along. “I’ll dilute it even further with 0.5 cc of lidocaine with epinephrine,” she said. “Then you can do serial punctures or you can thread along that line.”
For treating static rhytides on the neck, laser-resurfacing procedures work best, but at low settings. “Because there are fewer adnexal structures, the neck is at increased risk for scarring,” Dr. Ortiz said. “You want to use a lower fluence because your neck skin is thin. Your fluence determines your depth with resurfacing. Most importantly, use a lower density for a more conservative setting”
Options for treating poikiloderma of Civatte include the vascular laser, an IPL [intense pulsed light device], or a 1927-nm thulium laser. To avoid footprinting, or a “chicken wire” appearance to the treated area, Dr. Ortiz recommends using a large spot size with the pulsed dye laser or the IPL.
She concluded her presentation by underscoring the importance of communicating realistic expectations with patients. “There is some delayed gratification here,” she said. “For procedures that take time to see results, consider adding another procedure that will give them immediate results.”
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOA.
While if it involves the same area.
“Swelling from the laser can potentially make the toxin migrate and cause ptosis,” Arisa E. Ortiz, MD, said at the virtual annual Masters of Aesthetics Symposium. “Even though this is temporary, your patient’s not going to be very happy with you. I would separate these at least 1 day apart, and then you should be OK.”
When using a filler on the same day as a laser treatment, Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego, performs the laser procedure after injecting the filler, “because you may get some swelling, which can distort your need for filler,” she said. “I like to do the filler first to make sure I can assess how much volume loss they have. Then I’ll do the laser procedure right after.”
Another general rule of thumb is that, when combining lasers on the same day, consider lowering the device settings, “because it’s going to be a more aggressive treatment when you’re combining various laser procedures,” she said. “Treat vascular lesions first to not exacerbate nonspecific erythema. Then treat pigment, then resurfacing, followed by liquid nitrogen if needed to treat seborrheic keratoses.”
For periorbital rejuvenation, Dr. Ortiz likes to use a neurotoxin 1 week before performing the laser-resurfacing or skin-tightening procedure, followed by injection of a filler. “This augments your results,” she said. “Studies have shown that, if you start with a neuromodulator, you can get more improvement with your resurfacing procedure,” she said. “That makes sense, because you’re not contracting the muscle while you’re healing from the laser, so you get more effective collagen remodeling.”
When using a neuromodulator for dynamic periorbital rhytides, place it superficially to avoid bruising and stay superior to the maxillary prominence to avoid the zygomaticus major “so you don’t get a droopy smile,” she said. “The approved dosing is 24 units, 12 on each side. Less may be required for younger patients and more for more severe rhytides.”
For static rhytides, fractional resurfacing procedures will provide a more modest result with less downtime, while fully ablative laser resurfacing procedures will provide more dramatic improvement with more downtime. “You’re really going to tailor your treatment to what the patient is looking for,” Dr. Ortiz said. “If you use a fractional device you may need multiple treatments. Using a corneal shield when you’re resurfacing within the periorbital rim is a must, so you need to know how to place these if you’re going to be resurfacing in that area.”
For anesthesia, Dr. Ortiz likes to use injectable lidocaine, “because if you use a topical it can creep into the eye, and then you get a chemical corneal abrasion. This resolves after a few days but it’s really painful and your patient won’t be very happy.”
For tear troughs, use a hyaluronic acid filler with a low G prime. “If you use a thicker filler it can look lumpy or too full,” she said. While some clinicians use a needle to administer the filler, Dr. Ortiz prefers to use a blunt-tipped cannula. “It’s less painful and there’s less risk of bruising or swelling,” she said. “There’s also less risk of cannulizing a vessel. This is not zero risk. It’s been shown that the 27-gauge can actually cannulize the vessel, so it shouldn’t give you a false sense of security, but there is less risk, compared with using a needle. You can use the cannula to thread. If you’re using a needle you can inject a bolus and then massage it in, or you can use the microdroplet technique.”
With the cannula technique, bruising or swelling can occur even in the most experienced hands, “so make sure your patients don’t have an important event coming up,” Dr. Ortiz said. “With filler, not only do you improve the volume loss, but sometimes you improve the dark circles. I tend to see this more in lighter-skinned patients. In darker-skinned patients, the dark circles can be caused by racial pigmentation. That’s hard to fix, so I never promise that we can improve dark circles, but sometimes it does improve.”
For dynamic perioral rhytides, Dr. Ortiz generally treats with a neuromodulator 1 week in advance of laser resurfacing, followed by a filler for any etched-in lines. Use of a neuromodulator in the perioral region of musicians or singers is contraindicated “because it can affect their phonation,” she said. “Also, older patients might complain that it’s difficult for them to pucker their lips when they’re putting on a lip liner or lipstick. There are four injection sites on the upper lip and two on the lower lip. I do 1 unit at each injection site, with a max of 6-8 units. Any more than that and they’ll have difficulty puckering.”
Two main options for treating submental fullness include cryolipolysis or deoxycholic acid. “If you have a lot of volume, you want to use cryolipolysis,” Dr. Ortiz said. “The general rule is, if it fits in the cup [of the applicator], hook them up.” Use deoxycholic acid for areas of smaller volume, or to fine-tune, she added.
For platysmal bands, Dr. Ortiz favors injecting 2 units of botulinum toxin at three to four sites along the band. She pulls away and injects superficially and limits the treatment dose to 40 units in one session “because excessive doses can cause dysphagia,” she said. “If they need additional units, I’ll have them come back in 2 weeks.”
The Nefertiti lift combines the treatment of the platysma with the insertion point of the platysma along the jawline. Treatment of the patient along the lateral jawline with 2 units of botulinum toxin every centimeter or so can actually improve the definition of the jawline, “because your platysma is pulling down on your lower face,” Dr. Ortiz explained. “So, if you relax that, it can help to define the jawline. By treating the platysma, you can also prevent or soften the horizontal bands that occur across the neck.”
For necklace creases, she likes to inject 1-2 units of a low-HA filler along the crease – evenly spaced all along. “I’ll dilute it even further with 0.5 cc of lidocaine with epinephrine,” she said. “Then you can do serial punctures or you can thread along that line.”
For treating static rhytides on the neck, laser-resurfacing procedures work best, but at low settings. “Because there are fewer adnexal structures, the neck is at increased risk for scarring,” Dr. Ortiz said. “You want to use a lower fluence because your neck skin is thin. Your fluence determines your depth with resurfacing. Most importantly, use a lower density for a more conservative setting”
Options for treating poikiloderma of Civatte include the vascular laser, an IPL [intense pulsed light device], or a 1927-nm thulium laser. To avoid footprinting, or a “chicken wire” appearance to the treated area, Dr. Ortiz recommends using a large spot size with the pulsed dye laser or the IPL.
She concluded her presentation by underscoring the importance of communicating realistic expectations with patients. “There is some delayed gratification here,” she said. “For procedures that take time to see results, consider adding another procedure that will give them immediate results.”
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOA.
EXPERT ANALYSIS FROM MOA 2020
Counterfeits: An ugly truth in aesthetic medicine
according to the results of two recent surveys of such providers.
“Counterfeit medical devices and injectables may be more prevalent in aesthetic medicine than most practitioners might estimate,” Jordan V. Wang, MD, of Sidney Kimmel Medical College, Philadelphia, and associates wrote in Dermatologic Surgery, even though “the vast majority [believe] that they are inferior and even potentially harmful.”
In one of the online surveys, conducted among members of the American Society of Dermatologic Surgery, 41.1% of the 616 respondents said they had encountered counterfeit injectables, more than half (56.5%) of whom were solicited to buy such products. Just over 10% had purchased counterfeit injectables, although nearly 80% did so unknowingly, the investigators said.
In the second survey, 37.4% of the 765 respondents (members of the ASDS as well as the American Society for Laser Medicine and Surgery) said that they had encountered counterfeit medical devices, and nearly half had been approached to purchase such devices. Of those who were approached, 4.6% had actually purchased a counterfeit, but only 6.1% did so unknowingly, Dr. Wang and associates reported.
In the medical device survey, almost a quarter (24.2%) acknowledged that they know of other providers using them, while 29.3% of those surveyed about injectables know of others who use counterfeits, they said.
Over 90% of practitioners in each survey agreed that counterfeits are worse in terms of safety, reliability, and effectiveness, but the proportions were smaller when they were asked if counterfeits were either very or extremely endangering to patient safety: 70.5% for injectables and 59.2% for devices, the investigators said.
Experience with adverse events from counterfeits in patients was reported by 39.7% of respondents to the injectables survey and by 20.1% of those in the device survey, they added.
Majorities in both surveys – 73.7% for injectables and 68.9% for devices – also said that they were either not familiar or only somewhat familiar with the Food and Drug Administration’s regulations on counterfeits. “This is especially problematic considering the potentially severe adverse events and steep punishments,” Dr. Wang and associates wrote.
The authors disclosed that they had no significant interest with commercial supporters. Dr. Wang is now a fellow at the Laser & Skin Surgery Center of New York.
SOURCE: Wang JV et al. Dermatol. Surg. 2020 Oct;46(10):1323-6.
according to the results of two recent surveys of such providers.
“Counterfeit medical devices and injectables may be more prevalent in aesthetic medicine than most practitioners might estimate,” Jordan V. Wang, MD, of Sidney Kimmel Medical College, Philadelphia, and associates wrote in Dermatologic Surgery, even though “the vast majority [believe] that they are inferior and even potentially harmful.”
In one of the online surveys, conducted among members of the American Society of Dermatologic Surgery, 41.1% of the 616 respondents said they had encountered counterfeit injectables, more than half (56.5%) of whom were solicited to buy such products. Just over 10% had purchased counterfeit injectables, although nearly 80% did so unknowingly, the investigators said.
In the second survey, 37.4% of the 765 respondents (members of the ASDS as well as the American Society for Laser Medicine and Surgery) said that they had encountered counterfeit medical devices, and nearly half had been approached to purchase such devices. Of those who were approached, 4.6% had actually purchased a counterfeit, but only 6.1% did so unknowingly, Dr. Wang and associates reported.
In the medical device survey, almost a quarter (24.2%) acknowledged that they know of other providers using them, while 29.3% of those surveyed about injectables know of others who use counterfeits, they said.
Over 90% of practitioners in each survey agreed that counterfeits are worse in terms of safety, reliability, and effectiveness, but the proportions were smaller when they were asked if counterfeits were either very or extremely endangering to patient safety: 70.5% for injectables and 59.2% for devices, the investigators said.
Experience with adverse events from counterfeits in patients was reported by 39.7% of respondents to the injectables survey and by 20.1% of those in the device survey, they added.
Majorities in both surveys – 73.7% for injectables and 68.9% for devices – also said that they were either not familiar or only somewhat familiar with the Food and Drug Administration’s regulations on counterfeits. “This is especially problematic considering the potentially severe adverse events and steep punishments,” Dr. Wang and associates wrote.
The authors disclosed that they had no significant interest with commercial supporters. Dr. Wang is now a fellow at the Laser & Skin Surgery Center of New York.
SOURCE: Wang JV et al. Dermatol. Surg. 2020 Oct;46(10):1323-6.
according to the results of two recent surveys of such providers.
“Counterfeit medical devices and injectables may be more prevalent in aesthetic medicine than most practitioners might estimate,” Jordan V. Wang, MD, of Sidney Kimmel Medical College, Philadelphia, and associates wrote in Dermatologic Surgery, even though “the vast majority [believe] that they are inferior and even potentially harmful.”
In one of the online surveys, conducted among members of the American Society of Dermatologic Surgery, 41.1% of the 616 respondents said they had encountered counterfeit injectables, more than half (56.5%) of whom were solicited to buy such products. Just over 10% had purchased counterfeit injectables, although nearly 80% did so unknowingly, the investigators said.
In the second survey, 37.4% of the 765 respondents (members of the ASDS as well as the American Society for Laser Medicine and Surgery) said that they had encountered counterfeit medical devices, and nearly half had been approached to purchase such devices. Of those who were approached, 4.6% had actually purchased a counterfeit, but only 6.1% did so unknowingly, Dr. Wang and associates reported.
In the medical device survey, almost a quarter (24.2%) acknowledged that they know of other providers using them, while 29.3% of those surveyed about injectables know of others who use counterfeits, they said.
Over 90% of practitioners in each survey agreed that counterfeits are worse in terms of safety, reliability, and effectiveness, but the proportions were smaller when they were asked if counterfeits were either very or extremely endangering to patient safety: 70.5% for injectables and 59.2% for devices, the investigators said.
Experience with adverse events from counterfeits in patients was reported by 39.7% of respondents to the injectables survey and by 20.1% of those in the device survey, they added.
Majorities in both surveys – 73.7% for injectables and 68.9% for devices – also said that they were either not familiar or only somewhat familiar with the Food and Drug Administration’s regulations on counterfeits. “This is especially problematic considering the potentially severe adverse events and steep punishments,” Dr. Wang and associates wrote.
The authors disclosed that they had no significant interest with commercial supporters. Dr. Wang is now a fellow at the Laser & Skin Surgery Center of New York.
SOURCE: Wang JV et al. Dermatol. Surg. 2020 Oct;46(10):1323-6.
FROM DERMATOLOGIC SURGERY
Tailoring cosmetic procedures for skin of color patients minimize risks
Based on the fact that hyperpigmentation and other adverse events associated with cosmetic dermatologic procedures are relevant to skin type, not racial identification, individualized strategies to minimize the risk of potential adverse events are always appropriate, according to an expert speaking at the virtual Skin of Color Update 2020.
There are many highly effective interventions that employ lasers, chemical peels, and topical agents to achieve excellent cosmetic results in darker skin, but results are highly dependent on first understanding the relative risks and treatment goals, Cheryl Burgess, MD, president and founder of the Center for Dermatology and Dermatologic Surgery, Washington, D.C., said at the meeting.
She stressed the importance of educating patients that “all cosmetic procedures are not for skin of color.” Her approach is to engage patients on what they are trying to accomplish and then seeking a solution that tailors treatment to skin type based on the Fitzpatrick scale, the Roberts Hyperpigmentation Scale, or other guidance.
“There are so many different methods that we can use, and these are not necessarily the ones that patients have read about in a magazine,” Dr. Burgess said.
Intense pulsed laser (IPL) for hair removal is an example. This technique is not appropriate in patients with Fitzpatrick skin type IV or higher, according to Dr. Burgess, who presented a case example of a bad outcome. In this case, a patient came to her for treatment after exposure to IPL resulted in first- and second-degree burns complicated by extensive hypopigmentation.
Ultimately, the solution in this case involved more laser therapy, but this time a strategy was selected appropriate to skin of color.
“It is hard to suggest to a patient that we are going to use a laser device” when the problem was caused by a laser, Dr. Burgess observed, but properly selected lasers are effective and should be considered in patients with dark skin.
In this case, triple cream containing 6% hydroquinone was the first step towards resolving the hyperpigmentation. Jessner’s peel was also applied to increase penetration.
Laser treatment using two different types of devices was also employed: A 1,927-nm thulium-fractionated erbium glass laser and a 650-microsecond 1,064-nm Nd:YAG laser. The excellent resolution of the hyperpigmentation demonstrates that lasers are effective in dark skin when used appropriately, she noted.
Dr. Burgess emphasized that tailored therapy is not just relevant to Black patients. She cited data indicating that the proportion of multiracial individuals in the United States is increasing, and when tailoring cosmetic procedures, she recommended considering skin characteristics, not just skin color.
Relative to white skin, pigmented skin typically has greater elasticity, greater amounts of collagen, and greater oil content. Importantly, darker skin has a greater propensity to darkening as a result of injury, she said.
In a review of the hyperpigmentation process that follows injury or other insults, Dr. Burgess reported that only three occur inside the melanocyte. There are now topically applied agents to intervene at many of these steps, including hydroquinone to reduce up-regulation of tyrosinase enzymes, and cysteamine to inhibit conversion of DOPA to dopaquinone. All of these, often used in combination, offer potential benefit in skin of color.
However, “you must understand skin of color,” Dr. Burgess emphasized. For example, most hyaluronic acid dermal fillers can be considered in patients with Fitzpatrick skin types IV or higher with low risks for hypo- or hyperpigmentation, scarring, or keloid formation, but technique is important.
“There is more postinflammatory hyperpigmentation with serial or multiple puncture injection techniques” in dark skin relative to lighter skin, according to Dr. Burgess. She recommended reducing this risk with relatively slow injection times.
When in doubt about the result with any cosmetic procedure, test spots are a reasonable strategy, Dr. Burgess said. When there is concern about risk for adverse events, she recommended using low doses and longer intervals between treatments than might otherwise be considered. Patients should participate in understanding the rationale for selecting one approach over another.
It helps for patients to know that “the desired outcome may take many more sessions than what they read about in that we might have to consider conservative measures in order to ensure that we accomplish the cosmetic effect than they want,” she said.
It is critical that clinicians who perform laser or other cosmetic procedures on darker skin be aware of these precautions, agreed Eliot F. Battle Jr., MD, CEO and cofounder of Cultura Dermatology and Laser Center, Washington, D.C. “Over the past 20 years, we have improved lasers that can safely and effectively treat patients with skin of color, but we still have a way to go,” he said at the meeting. Darker skin behaves differently in response to this energy.
“The pigment in the skin of patients of color competes for the laser light, which can cause heat-related side effects, like blistering and pigmentary changes. Skin of color also has an increased incidence of scarring and unwanted pigmentary changes from laser treatments that create irritation and inflammation,” he explained.
It is important to be aware of these differences, but practitioners also “need to treat conservatively to minimize these unwanted side effects,” Dr. Battle said.
Dr. Burgess reported financial relationships with Allergan, Merz Aesthetics, Revance Therapeutics, and Galderma. Dr. Battle had no commercial disclosures.
Based on the fact that hyperpigmentation and other adverse events associated with cosmetic dermatologic procedures are relevant to skin type, not racial identification, individualized strategies to minimize the risk of potential adverse events are always appropriate, according to an expert speaking at the virtual Skin of Color Update 2020.
There are many highly effective interventions that employ lasers, chemical peels, and topical agents to achieve excellent cosmetic results in darker skin, but results are highly dependent on first understanding the relative risks and treatment goals, Cheryl Burgess, MD, president and founder of the Center for Dermatology and Dermatologic Surgery, Washington, D.C., said at the meeting.
She stressed the importance of educating patients that “all cosmetic procedures are not for skin of color.” Her approach is to engage patients on what they are trying to accomplish and then seeking a solution that tailors treatment to skin type based on the Fitzpatrick scale, the Roberts Hyperpigmentation Scale, or other guidance.
“There are so many different methods that we can use, and these are not necessarily the ones that patients have read about in a magazine,” Dr. Burgess said.
Intense pulsed laser (IPL) for hair removal is an example. This technique is not appropriate in patients with Fitzpatrick skin type IV or higher, according to Dr. Burgess, who presented a case example of a bad outcome. In this case, a patient came to her for treatment after exposure to IPL resulted in first- and second-degree burns complicated by extensive hypopigmentation.
Ultimately, the solution in this case involved more laser therapy, but this time a strategy was selected appropriate to skin of color.
“It is hard to suggest to a patient that we are going to use a laser device” when the problem was caused by a laser, Dr. Burgess observed, but properly selected lasers are effective and should be considered in patients with dark skin.
In this case, triple cream containing 6% hydroquinone was the first step towards resolving the hyperpigmentation. Jessner’s peel was also applied to increase penetration.
Laser treatment using two different types of devices was also employed: A 1,927-nm thulium-fractionated erbium glass laser and a 650-microsecond 1,064-nm Nd:YAG laser. The excellent resolution of the hyperpigmentation demonstrates that lasers are effective in dark skin when used appropriately, she noted.
Dr. Burgess emphasized that tailored therapy is not just relevant to Black patients. She cited data indicating that the proportion of multiracial individuals in the United States is increasing, and when tailoring cosmetic procedures, she recommended considering skin characteristics, not just skin color.
Relative to white skin, pigmented skin typically has greater elasticity, greater amounts of collagen, and greater oil content. Importantly, darker skin has a greater propensity to darkening as a result of injury, she said.
In a review of the hyperpigmentation process that follows injury or other insults, Dr. Burgess reported that only three occur inside the melanocyte. There are now topically applied agents to intervene at many of these steps, including hydroquinone to reduce up-regulation of tyrosinase enzymes, and cysteamine to inhibit conversion of DOPA to dopaquinone. All of these, often used in combination, offer potential benefit in skin of color.
However, “you must understand skin of color,” Dr. Burgess emphasized. For example, most hyaluronic acid dermal fillers can be considered in patients with Fitzpatrick skin types IV or higher with low risks for hypo- or hyperpigmentation, scarring, or keloid formation, but technique is important.
“There is more postinflammatory hyperpigmentation with serial or multiple puncture injection techniques” in dark skin relative to lighter skin, according to Dr. Burgess. She recommended reducing this risk with relatively slow injection times.
When in doubt about the result with any cosmetic procedure, test spots are a reasonable strategy, Dr. Burgess said. When there is concern about risk for adverse events, she recommended using low doses and longer intervals between treatments than might otherwise be considered. Patients should participate in understanding the rationale for selecting one approach over another.
It helps for patients to know that “the desired outcome may take many more sessions than what they read about in that we might have to consider conservative measures in order to ensure that we accomplish the cosmetic effect than they want,” she said.
It is critical that clinicians who perform laser or other cosmetic procedures on darker skin be aware of these precautions, agreed Eliot F. Battle Jr., MD, CEO and cofounder of Cultura Dermatology and Laser Center, Washington, D.C. “Over the past 20 years, we have improved lasers that can safely and effectively treat patients with skin of color, but we still have a way to go,” he said at the meeting. Darker skin behaves differently in response to this energy.
“The pigment in the skin of patients of color competes for the laser light, which can cause heat-related side effects, like blistering and pigmentary changes. Skin of color also has an increased incidence of scarring and unwanted pigmentary changes from laser treatments that create irritation and inflammation,” he explained.
It is important to be aware of these differences, but practitioners also “need to treat conservatively to minimize these unwanted side effects,” Dr. Battle said.
Dr. Burgess reported financial relationships with Allergan, Merz Aesthetics, Revance Therapeutics, and Galderma. Dr. Battle had no commercial disclosures.
Based on the fact that hyperpigmentation and other adverse events associated with cosmetic dermatologic procedures are relevant to skin type, not racial identification, individualized strategies to minimize the risk of potential adverse events are always appropriate, according to an expert speaking at the virtual Skin of Color Update 2020.
There are many highly effective interventions that employ lasers, chemical peels, and topical agents to achieve excellent cosmetic results in darker skin, but results are highly dependent on first understanding the relative risks and treatment goals, Cheryl Burgess, MD, president and founder of the Center for Dermatology and Dermatologic Surgery, Washington, D.C., said at the meeting.
She stressed the importance of educating patients that “all cosmetic procedures are not for skin of color.” Her approach is to engage patients on what they are trying to accomplish and then seeking a solution that tailors treatment to skin type based on the Fitzpatrick scale, the Roberts Hyperpigmentation Scale, or other guidance.
“There are so many different methods that we can use, and these are not necessarily the ones that patients have read about in a magazine,” Dr. Burgess said.
Intense pulsed laser (IPL) for hair removal is an example. This technique is not appropriate in patients with Fitzpatrick skin type IV or higher, according to Dr. Burgess, who presented a case example of a bad outcome. In this case, a patient came to her for treatment after exposure to IPL resulted in first- and second-degree burns complicated by extensive hypopigmentation.
Ultimately, the solution in this case involved more laser therapy, but this time a strategy was selected appropriate to skin of color.
“It is hard to suggest to a patient that we are going to use a laser device” when the problem was caused by a laser, Dr. Burgess observed, but properly selected lasers are effective and should be considered in patients with dark skin.
In this case, triple cream containing 6% hydroquinone was the first step towards resolving the hyperpigmentation. Jessner’s peel was also applied to increase penetration.
Laser treatment using two different types of devices was also employed: A 1,927-nm thulium-fractionated erbium glass laser and a 650-microsecond 1,064-nm Nd:YAG laser. The excellent resolution of the hyperpigmentation demonstrates that lasers are effective in dark skin when used appropriately, she noted.
Dr. Burgess emphasized that tailored therapy is not just relevant to Black patients. She cited data indicating that the proportion of multiracial individuals in the United States is increasing, and when tailoring cosmetic procedures, she recommended considering skin characteristics, not just skin color.
Relative to white skin, pigmented skin typically has greater elasticity, greater amounts of collagen, and greater oil content. Importantly, darker skin has a greater propensity to darkening as a result of injury, she said.
In a review of the hyperpigmentation process that follows injury or other insults, Dr. Burgess reported that only three occur inside the melanocyte. There are now topically applied agents to intervene at many of these steps, including hydroquinone to reduce up-regulation of tyrosinase enzymes, and cysteamine to inhibit conversion of DOPA to dopaquinone. All of these, often used in combination, offer potential benefit in skin of color.
However, “you must understand skin of color,” Dr. Burgess emphasized. For example, most hyaluronic acid dermal fillers can be considered in patients with Fitzpatrick skin types IV or higher with low risks for hypo- or hyperpigmentation, scarring, or keloid formation, but technique is important.
“There is more postinflammatory hyperpigmentation with serial or multiple puncture injection techniques” in dark skin relative to lighter skin, according to Dr. Burgess. She recommended reducing this risk with relatively slow injection times.
When in doubt about the result with any cosmetic procedure, test spots are a reasonable strategy, Dr. Burgess said. When there is concern about risk for adverse events, she recommended using low doses and longer intervals between treatments than might otherwise be considered. Patients should participate in understanding the rationale for selecting one approach over another.
It helps for patients to know that “the desired outcome may take many more sessions than what they read about in that we might have to consider conservative measures in order to ensure that we accomplish the cosmetic effect than they want,” she said.
It is critical that clinicians who perform laser or other cosmetic procedures on darker skin be aware of these precautions, agreed Eliot F. Battle Jr., MD, CEO and cofounder of Cultura Dermatology and Laser Center, Washington, D.C. “Over the past 20 years, we have improved lasers that can safely and effectively treat patients with skin of color, but we still have a way to go,” he said at the meeting. Darker skin behaves differently in response to this energy.
“The pigment in the skin of patients of color competes for the laser light, which can cause heat-related side effects, like blistering and pigmentary changes. Skin of color also has an increased incidence of scarring and unwanted pigmentary changes from laser treatments that create irritation and inflammation,” he explained.
It is important to be aware of these differences, but practitioners also “need to treat conservatively to minimize these unwanted side effects,” Dr. Battle said.
Dr. Burgess reported financial relationships with Allergan, Merz Aesthetics, Revance Therapeutics, and Galderma. Dr. Battle had no commercial disclosures.
FROM SOC 2020
Hair oiling: Practices, benefits, and caveats
including in India and among people of the African diaspora. Hair oiling typically entails combing the hair, followed by applying oil from the roots to the ends about once a week prior to shampooing. Hair oiling daily or every other day, often with a hair braid, is also practiced, using coconut oil or other oils. Oil is found in various hair products and has been popular in the United States, particularly as hot oil treatments in the 1980s.
Oils are used as part of Abhyanga massage, either by an Ayurvedic practitioner or as self-massage, as part of ancient Indian Ayurvedic medicine practice. The type of oil used is determined by the practitioner depending on the individual’s needs; cold-pressed sesame oil or coconut oil is often used as the base oil. Abhyanga is often performed with oil on the entire body as an act of self-care, which includes massage of the hair and scalp. The oil and herbs that are often added to the oil, as well as the scalp massage itself, are explained by practitioners as having therapeutic effects on the hair, including exfoliation of a dry scalp and on overall well-being. Outside of Ayurvedic medicine, hair oiling is also sometimes performed in India as part of routine hair care and can be a bonding experience among parents, grandparents, and children.
Amla oil, which is derived from Indian gooseberry (Phyllanthus emblica L.) and is often used in India on the hair, contains Vitamin C and has been shown to have activity against dermatophytes. In a study conducted in India, amla oil was found to have the most activity against Microsporum canis, M. gypseum, and Trichophyton rubrum, followed by cantharidine and coconut oil, while T. mentagrophytes was most susceptible to coconut oil, followed by amla and cantharidine oil.1 A study conducted in mice in Thailand found that 5-alpha-reductase was reduced with the dried form of the herb Phyllanthus emblica L, as well as with some other traditional Thai herbs used as hair treatments.2
Castor oil has been utilized in many cultures to promote hair growth. Ricinoleic acid, an unsaturated omega-9 fatty acid and hydroxy acid, is the major component of seed oil obtained from mature castor plants. It has anti-inflammatory and antimicrobial effects, and in one study,3 was found to inhibit prostaglandin D2, which has been implicated in the pathogenesis of androgenetic alopecia.4 Jamaican black castor oil is darker in color and has a more alkaline pH compared with traditional castor oil (both contain ricinoleic acid). To produce Jamaican black castor oil, the seed is roasted, ground to a thick paste, boiled in a pot of hot water, then the oil is skimmed off of the top into individual bottles, whereas regular castor oil is cold pressed. The alkalinity of Jamaican black castor oil may play a role in opening up the hair cuticle, which may be beneficial, but application also needs to be followed by a routine that includes closing the cuticle to avoid increasing hair fragility; such a routine could include, for example, leave-in conditioner or rinsing conditioner with colder water.
Castor oil is sometimes used on its own or in combination with other oils, and it is also an ingredient in some hair care products. However, publicly available peer-reviewed research articles demonstrating the effects of castor oil when applied directly to the hair and scalp for hair growth are needed.
Different types of hair oils are used in African American hair care products and, worldwide, by people of the African diaspora as part of regular hair care and hair styling. Common oils include jojoba, coconut, castor, argan, olive, sunflower, and almond oils. Very curly hair often dries out more easily, especially in drier climates; and sebum build-up on the scalp does not occur as quickly, so hair typically does not need to be shampooed frequently. As such, over-shampooing also often dries the hair out faster, especially if hair has been chemically processed. Thus, oils help to coat and protect the hair, and smooth the cuticle. Oils themselves do not moisturize, but can seal moisture into the hair or act as humectants and draw moisture in. Rather than applying on dry hair, oils, when used as daily care as opposed to before shampooing, are often applied on clean hair after shampooing and after a leave-in conditioner has been applied to help seal in moisture for the most benefit. For treatment of scalp conditions, depending on the type of hair care practice performed at home, oils may be preferred over potentially drying solutions and foams if available, for optimum hair care.
Hair oiling is a long-standing practice which, when used correctly, can be beneficial for hair management and health. There are, however, caveats to hair oiling, which include being careful not to excessively brush or comb hair that has a lot of oil in it because the hair is slick, which can cause hair to fall out during combing. Some oils have elevated levels of lauric acid (coconut oil has 50%), which has a high affinity for hair proteins.5 While this can support hair strength, care should be taken not to overuse some oils or other products known as “protein packs,” which should be used as directed. Since hair is protein, excess protein build-up coating the hair can block needed moisture, making the hair more knotted and brittle, potentially resulting in more breakage with brushing or other hair care practices.
Some oil-containing hair products also contain artificial fragrances and/or dyes, which in some individuals, may promote an immunogenic effect, such as contact dermatitis. Certain oils, particularly olive oil, can promote an environment favorable to yeast growth, especially Malassezia species, implicated in seborrheic dermatitis. Practices that involve excessive application of oil to the scalp can also result in build up if not shampooed regularly. Sulfonated castor oil (also known as Turkey Red oil) has been reported to cause contact dermatitis.6
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
including in India and among people of the African diaspora. Hair oiling typically entails combing the hair, followed by applying oil from the roots to the ends about once a week prior to shampooing. Hair oiling daily or every other day, often with a hair braid, is also practiced, using coconut oil or other oils. Oil is found in various hair products and has been popular in the United States, particularly as hot oil treatments in the 1980s.
Oils are used as part of Abhyanga massage, either by an Ayurvedic practitioner or as self-massage, as part of ancient Indian Ayurvedic medicine practice. The type of oil used is determined by the practitioner depending on the individual’s needs; cold-pressed sesame oil or coconut oil is often used as the base oil. Abhyanga is often performed with oil on the entire body as an act of self-care, which includes massage of the hair and scalp. The oil and herbs that are often added to the oil, as well as the scalp massage itself, are explained by practitioners as having therapeutic effects on the hair, including exfoliation of a dry scalp and on overall well-being. Outside of Ayurvedic medicine, hair oiling is also sometimes performed in India as part of routine hair care and can be a bonding experience among parents, grandparents, and children.
Amla oil, which is derived from Indian gooseberry (Phyllanthus emblica L.) and is often used in India on the hair, contains Vitamin C and has been shown to have activity against dermatophytes. In a study conducted in India, amla oil was found to have the most activity against Microsporum canis, M. gypseum, and Trichophyton rubrum, followed by cantharidine and coconut oil, while T. mentagrophytes was most susceptible to coconut oil, followed by amla and cantharidine oil.1 A study conducted in mice in Thailand found that 5-alpha-reductase was reduced with the dried form of the herb Phyllanthus emblica L, as well as with some other traditional Thai herbs used as hair treatments.2
Castor oil has been utilized in many cultures to promote hair growth. Ricinoleic acid, an unsaturated omega-9 fatty acid and hydroxy acid, is the major component of seed oil obtained from mature castor plants. It has anti-inflammatory and antimicrobial effects, and in one study,3 was found to inhibit prostaglandin D2, which has been implicated in the pathogenesis of androgenetic alopecia.4 Jamaican black castor oil is darker in color and has a more alkaline pH compared with traditional castor oil (both contain ricinoleic acid). To produce Jamaican black castor oil, the seed is roasted, ground to a thick paste, boiled in a pot of hot water, then the oil is skimmed off of the top into individual bottles, whereas regular castor oil is cold pressed. The alkalinity of Jamaican black castor oil may play a role in opening up the hair cuticle, which may be beneficial, but application also needs to be followed by a routine that includes closing the cuticle to avoid increasing hair fragility; such a routine could include, for example, leave-in conditioner or rinsing conditioner with colder water.
Castor oil is sometimes used on its own or in combination with other oils, and it is also an ingredient in some hair care products. However, publicly available peer-reviewed research articles demonstrating the effects of castor oil when applied directly to the hair and scalp for hair growth are needed.
Different types of hair oils are used in African American hair care products and, worldwide, by people of the African diaspora as part of regular hair care and hair styling. Common oils include jojoba, coconut, castor, argan, olive, sunflower, and almond oils. Very curly hair often dries out more easily, especially in drier climates; and sebum build-up on the scalp does not occur as quickly, so hair typically does not need to be shampooed frequently. As such, over-shampooing also often dries the hair out faster, especially if hair has been chemically processed. Thus, oils help to coat and protect the hair, and smooth the cuticle. Oils themselves do not moisturize, but can seal moisture into the hair or act as humectants and draw moisture in. Rather than applying on dry hair, oils, when used as daily care as opposed to before shampooing, are often applied on clean hair after shampooing and after a leave-in conditioner has been applied to help seal in moisture for the most benefit. For treatment of scalp conditions, depending on the type of hair care practice performed at home, oils may be preferred over potentially drying solutions and foams if available, for optimum hair care.
Hair oiling is a long-standing practice which, when used correctly, can be beneficial for hair management and health. There are, however, caveats to hair oiling, which include being careful not to excessively brush or comb hair that has a lot of oil in it because the hair is slick, which can cause hair to fall out during combing. Some oils have elevated levels of lauric acid (coconut oil has 50%), which has a high affinity for hair proteins.5 While this can support hair strength, care should be taken not to overuse some oils or other products known as “protein packs,” which should be used as directed. Since hair is protein, excess protein build-up coating the hair can block needed moisture, making the hair more knotted and brittle, potentially resulting in more breakage with brushing or other hair care practices.
Some oil-containing hair products also contain artificial fragrances and/or dyes, which in some individuals, may promote an immunogenic effect, such as contact dermatitis. Certain oils, particularly olive oil, can promote an environment favorable to yeast growth, especially Malassezia species, implicated in seborrheic dermatitis. Practices that involve excessive application of oil to the scalp can also result in build up if not shampooed regularly. Sulfonated castor oil (also known as Turkey Red oil) has been reported to cause contact dermatitis.6
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
including in India and among people of the African diaspora. Hair oiling typically entails combing the hair, followed by applying oil from the roots to the ends about once a week prior to shampooing. Hair oiling daily or every other day, often with a hair braid, is also practiced, using coconut oil or other oils. Oil is found in various hair products and has been popular in the United States, particularly as hot oil treatments in the 1980s.
Oils are used as part of Abhyanga massage, either by an Ayurvedic practitioner or as self-massage, as part of ancient Indian Ayurvedic medicine practice. The type of oil used is determined by the practitioner depending on the individual’s needs; cold-pressed sesame oil or coconut oil is often used as the base oil. Abhyanga is often performed with oil on the entire body as an act of self-care, which includes massage of the hair and scalp. The oil and herbs that are often added to the oil, as well as the scalp massage itself, are explained by practitioners as having therapeutic effects on the hair, including exfoliation of a dry scalp and on overall well-being. Outside of Ayurvedic medicine, hair oiling is also sometimes performed in India as part of routine hair care and can be a bonding experience among parents, grandparents, and children.
Amla oil, which is derived from Indian gooseberry (Phyllanthus emblica L.) and is often used in India on the hair, contains Vitamin C and has been shown to have activity against dermatophytes. In a study conducted in India, amla oil was found to have the most activity against Microsporum canis, M. gypseum, and Trichophyton rubrum, followed by cantharidine and coconut oil, while T. mentagrophytes was most susceptible to coconut oil, followed by amla and cantharidine oil.1 A study conducted in mice in Thailand found that 5-alpha-reductase was reduced with the dried form of the herb Phyllanthus emblica L, as well as with some other traditional Thai herbs used as hair treatments.2
Castor oil has been utilized in many cultures to promote hair growth. Ricinoleic acid, an unsaturated omega-9 fatty acid and hydroxy acid, is the major component of seed oil obtained from mature castor plants. It has anti-inflammatory and antimicrobial effects, and in one study,3 was found to inhibit prostaglandin D2, which has been implicated in the pathogenesis of androgenetic alopecia.4 Jamaican black castor oil is darker in color and has a more alkaline pH compared with traditional castor oil (both contain ricinoleic acid). To produce Jamaican black castor oil, the seed is roasted, ground to a thick paste, boiled in a pot of hot water, then the oil is skimmed off of the top into individual bottles, whereas regular castor oil is cold pressed. The alkalinity of Jamaican black castor oil may play a role in opening up the hair cuticle, which may be beneficial, but application also needs to be followed by a routine that includes closing the cuticle to avoid increasing hair fragility; such a routine could include, for example, leave-in conditioner or rinsing conditioner with colder water.
Castor oil is sometimes used on its own or in combination with other oils, and it is also an ingredient in some hair care products. However, publicly available peer-reviewed research articles demonstrating the effects of castor oil when applied directly to the hair and scalp for hair growth are needed.
Different types of hair oils are used in African American hair care products and, worldwide, by people of the African diaspora as part of regular hair care and hair styling. Common oils include jojoba, coconut, castor, argan, olive, sunflower, and almond oils. Very curly hair often dries out more easily, especially in drier climates; and sebum build-up on the scalp does not occur as quickly, so hair typically does not need to be shampooed frequently. As such, over-shampooing also often dries the hair out faster, especially if hair has been chemically processed. Thus, oils help to coat and protect the hair, and smooth the cuticle. Oils themselves do not moisturize, but can seal moisture into the hair or act as humectants and draw moisture in. Rather than applying on dry hair, oils, when used as daily care as opposed to before shampooing, are often applied on clean hair after shampooing and after a leave-in conditioner has been applied to help seal in moisture for the most benefit. For treatment of scalp conditions, depending on the type of hair care practice performed at home, oils may be preferred over potentially drying solutions and foams if available, for optimum hair care.
Hair oiling is a long-standing practice which, when used correctly, can be beneficial for hair management and health. There are, however, caveats to hair oiling, which include being careful not to excessively brush or comb hair that has a lot of oil in it because the hair is slick, which can cause hair to fall out during combing. Some oils have elevated levels of lauric acid (coconut oil has 50%), which has a high affinity for hair proteins.5 While this can support hair strength, care should be taken not to overuse some oils or other products known as “protein packs,” which should be used as directed. Since hair is protein, excess protein build-up coating the hair can block needed moisture, making the hair more knotted and brittle, potentially resulting in more breakage with brushing or other hair care practices.
Some oil-containing hair products also contain artificial fragrances and/or dyes, which in some individuals, may promote an immunogenic effect, such as contact dermatitis. Certain oils, particularly olive oil, can promote an environment favorable to yeast growth, especially Malassezia species, implicated in seborrheic dermatitis. Practices that involve excessive application of oil to the scalp can also result in build up if not shampooed regularly. Sulfonated castor oil (also known as Turkey Red oil) has been reported to cause contact dermatitis.6
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
More on the history of dermatologists and skin care
Thanks to all the readers of Part 1 (The interesting history of dermatologist-developed skin care), who gave me interesting feedback on my Facebook and LinkedIn accounts. There was so much interest that I will write Part 3 next month. Feel free to DM me your ideas on LinkedIn.
The history of dermatologist-developed skin care continues as more dermatologists become interested in developing a skin care line or retailing skin care in their medical practice. A report in July 2020 showed that physician-dispensed skin care is the largest growing segment of the skin care business with a projected compound annual growth rate of 9.9% from 2020 to 2027. I have not seen national sales numbers since this July report, but we have noticed a large increase in online sales for the doctors using my Skin Type Solutions System. This is most likely because, in a national crisis, the self-care and beauty business segments often see growth. So as you can see, dermatologist-dispensed skin care is becoming a major player in national skin care sales. Let’s get back to the story of how this came to be the case.
Peter Elias, MD. Dr. Elias is professor in the department of dermatology at the University of California, San Francisco. In 1996, Dr. Elias published a landmark paper in the Journal of Investigative Dermatology demonstrating that a 1:1:1 ratio of ceramides, fatty acids, and cholesterol is required to repair a damaged skin barrier. He filed multiple patents for using these lipids in moisturizers as early as 1992. His lipid research has stood the test of time, and this paper is still frequently cited. Dr. Elias has authored over 500 peer reviewed articles on the skin barrier, has edited or coauthored three books on skin barrier science, and developed EpiCeram, a product that utilizes ceramide, the fatty acid linoleic acid, and cholesterol. EpiCeram is the only barrier repair moisturizer approved by the Food and Drug Administration and is available by prescription only.
Kathy Fields, MD, and Katie Rodan, MD. Dr. Fields and Dr. Rodan met at Stanford (Calif.) University. In the 1980s, these entrepreneurial dermatologists realized that patients did not understand the role of preventing acne rather than just treating it. As dermatologists, they knew that a consistent daily routine to prevent acne was much more effective than waiting for an outbreak and spot-treating lesions. They took an already available OTC medication – benzoyl peroxide – and educated consumers through infomercials that they needed to stay ahead of acne instead of waiting for a breakout. Using infomercials to sell skin care, selling skin care kits, and educating patients about the need to prevent acne rather than spot treat it was very unusual at the time. As we all know, reeducating your patients is a huge challenge. Dr. Fields and Dr. Rodan changed consumers thinking in a genius way that continues to resonate today by choosing a brand name to make their point: Proactiv. Their simple 3-step acne kit encouraged patients to be proactive about their acne and encouraged compliance. (Patients love exact skin care steps as demonstrated again by the success of the skin care line from plastic surgeon Suzan Obagi, MD, which became available around 1988).
Dr. Fields and Dr. Rodan first offered Proactiv to Neutrogena, which turned it down. This early disappointment did not deter them and ended up benefiting them because this gave them the idea to do infomercials. Guthy Renker agreed to market and distribute the product, and the first Proactiv infomercial appeared on TV in 1995. It quickly became popular and is still one of the best selling skin care lines of all time. It’s important to note that the “overnight success” of Proactiv took at least a decade of effort.
Dr. Rodan and Dr. Fields started a new skin care line called Rodan and Fields in 2002, which was sold in department stores. This was at a time when department stores were losing market share of the skin care business, and Dr. Rodan and Dr. Fields wisely relaunched in 2007 using a direct sales model similar to Mary Kay and Avon. Their ability to encourage and motivate their team is apparent in the enthusiasm seen in their sales consultants.
Heather Woolery Lloyd, MD. Dr. Woolery Lloyd got her medical degree at the University of Miami where she also completed her dermatology residency. Her interest in skin of color led to her appointment as director of Ethnic Skin Care at the University of Miami, the country’s first cosmetic ethnic skin care department at a major university. She spent years lecturing around the world on skin of color issues and performing clinical trials before she developed the “Specific Beauty” skin care line for melanin rich skin types. Specific Beauty was acquired by Guthy Renker and is available online. It is the most popular dermatologist developed skin care line for skin of color.
In the late 1980s and early 1990s, other dermatologists threw their hats into the ring and came out with skin care lines – some successful and some not. Unfortunately, many skin care lines at that time were based on “pseudoscience” and exaggerated claims, which fueled the fire of those who felt dermatologists should steer clear of these entrepreneurial pursuits. A debate about the ethics of doctors retailing skin care began, and the controversy led to this 2010 statement by the American Medical Association: “In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.”
Many dermatologists dropped out of the AMA as a result because they felt the organization was no longer representing dermatologist’s interests. After all, we know skin care science better than anyone, and many dermatologists were insulted by the suggestion that we would place our personal financial gain over the best interests of our patients.
This is a perfect example of how the actions of a few unscrupulous dermatologists can affect the entire specialty. I like to focus on the ethical entrepreneurial dermatologists who made great contributions to the skin care industry based on science, efficacy, and patient education and encourage the ethical among us to provide this science-based information to our patients to protect them from pseudoscience-based opportunists. It is obvious that I believe that dermatologists have a responsibility to provide medical advice on skin care to their patients. If not us, who will do it as ethically as we will? But I plead with those of you out there who are promoting foolish stem cell–containing creams and other impossible technologies to remember that you are hurting the credibility of our entire dermatology profession.
In my next column, I will discuss dermatologists who have played a significant role behind the scenes in the development of the skin care industry.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
Castanedo-Tardan MP, Baumann L. Clin Dermatol. Jul-Aug 2009;27(4):355-8.
Gormley DE. Arch Dermatol. 1999 Jul;135(7):765-6.
Miller RC. Arch Dermatol. 1999 Mar;135(3):255-6.
Virtual Mentor. 2010;12(12):925-7.
Thanks to all the readers of Part 1 (The interesting history of dermatologist-developed skin care), who gave me interesting feedback on my Facebook and LinkedIn accounts. There was so much interest that I will write Part 3 next month. Feel free to DM me your ideas on LinkedIn.
The history of dermatologist-developed skin care continues as more dermatologists become interested in developing a skin care line or retailing skin care in their medical practice. A report in July 2020 showed that physician-dispensed skin care is the largest growing segment of the skin care business with a projected compound annual growth rate of 9.9% from 2020 to 2027. I have not seen national sales numbers since this July report, but we have noticed a large increase in online sales for the doctors using my Skin Type Solutions System. This is most likely because, in a national crisis, the self-care and beauty business segments often see growth. So as you can see, dermatologist-dispensed skin care is becoming a major player in national skin care sales. Let’s get back to the story of how this came to be the case.
Peter Elias, MD. Dr. Elias is professor in the department of dermatology at the University of California, San Francisco. In 1996, Dr. Elias published a landmark paper in the Journal of Investigative Dermatology demonstrating that a 1:1:1 ratio of ceramides, fatty acids, and cholesterol is required to repair a damaged skin barrier. He filed multiple patents for using these lipids in moisturizers as early as 1992. His lipid research has stood the test of time, and this paper is still frequently cited. Dr. Elias has authored over 500 peer reviewed articles on the skin barrier, has edited or coauthored three books on skin barrier science, and developed EpiCeram, a product that utilizes ceramide, the fatty acid linoleic acid, and cholesterol. EpiCeram is the only barrier repair moisturizer approved by the Food and Drug Administration and is available by prescription only.
Kathy Fields, MD, and Katie Rodan, MD. Dr. Fields and Dr. Rodan met at Stanford (Calif.) University. In the 1980s, these entrepreneurial dermatologists realized that patients did not understand the role of preventing acne rather than just treating it. As dermatologists, they knew that a consistent daily routine to prevent acne was much more effective than waiting for an outbreak and spot-treating lesions. They took an already available OTC medication – benzoyl peroxide – and educated consumers through infomercials that they needed to stay ahead of acne instead of waiting for a breakout. Using infomercials to sell skin care, selling skin care kits, and educating patients about the need to prevent acne rather than spot treat it was very unusual at the time. As we all know, reeducating your patients is a huge challenge. Dr. Fields and Dr. Rodan changed consumers thinking in a genius way that continues to resonate today by choosing a brand name to make their point: Proactiv. Their simple 3-step acne kit encouraged patients to be proactive about their acne and encouraged compliance. (Patients love exact skin care steps as demonstrated again by the success of the skin care line from plastic surgeon Suzan Obagi, MD, which became available around 1988).
Dr. Fields and Dr. Rodan first offered Proactiv to Neutrogena, which turned it down. This early disappointment did not deter them and ended up benefiting them because this gave them the idea to do infomercials. Guthy Renker agreed to market and distribute the product, and the first Proactiv infomercial appeared on TV in 1995. It quickly became popular and is still one of the best selling skin care lines of all time. It’s important to note that the “overnight success” of Proactiv took at least a decade of effort.
Dr. Rodan and Dr. Fields started a new skin care line called Rodan and Fields in 2002, which was sold in department stores. This was at a time when department stores were losing market share of the skin care business, and Dr. Rodan and Dr. Fields wisely relaunched in 2007 using a direct sales model similar to Mary Kay and Avon. Their ability to encourage and motivate their team is apparent in the enthusiasm seen in their sales consultants.
Heather Woolery Lloyd, MD. Dr. Woolery Lloyd got her medical degree at the University of Miami where she also completed her dermatology residency. Her interest in skin of color led to her appointment as director of Ethnic Skin Care at the University of Miami, the country’s first cosmetic ethnic skin care department at a major university. She spent years lecturing around the world on skin of color issues and performing clinical trials before she developed the “Specific Beauty” skin care line for melanin rich skin types. Specific Beauty was acquired by Guthy Renker and is available online. It is the most popular dermatologist developed skin care line for skin of color.
In the late 1980s and early 1990s, other dermatologists threw their hats into the ring and came out with skin care lines – some successful and some not. Unfortunately, many skin care lines at that time were based on “pseudoscience” and exaggerated claims, which fueled the fire of those who felt dermatologists should steer clear of these entrepreneurial pursuits. A debate about the ethics of doctors retailing skin care began, and the controversy led to this 2010 statement by the American Medical Association: “In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.”
Many dermatologists dropped out of the AMA as a result because they felt the organization was no longer representing dermatologist’s interests. After all, we know skin care science better than anyone, and many dermatologists were insulted by the suggestion that we would place our personal financial gain over the best interests of our patients.
This is a perfect example of how the actions of a few unscrupulous dermatologists can affect the entire specialty. I like to focus on the ethical entrepreneurial dermatologists who made great contributions to the skin care industry based on science, efficacy, and patient education and encourage the ethical among us to provide this science-based information to our patients to protect them from pseudoscience-based opportunists. It is obvious that I believe that dermatologists have a responsibility to provide medical advice on skin care to their patients. If not us, who will do it as ethically as we will? But I plead with those of you out there who are promoting foolish stem cell–containing creams and other impossible technologies to remember that you are hurting the credibility of our entire dermatology profession.
In my next column, I will discuss dermatologists who have played a significant role behind the scenes in the development of the skin care industry.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
Castanedo-Tardan MP, Baumann L. Clin Dermatol. Jul-Aug 2009;27(4):355-8.
Gormley DE. Arch Dermatol. 1999 Jul;135(7):765-6.
Miller RC. Arch Dermatol. 1999 Mar;135(3):255-6.
Virtual Mentor. 2010;12(12):925-7.
Thanks to all the readers of Part 1 (The interesting history of dermatologist-developed skin care), who gave me interesting feedback on my Facebook and LinkedIn accounts. There was so much interest that I will write Part 3 next month. Feel free to DM me your ideas on LinkedIn.
The history of dermatologist-developed skin care continues as more dermatologists become interested in developing a skin care line or retailing skin care in their medical practice. A report in July 2020 showed that physician-dispensed skin care is the largest growing segment of the skin care business with a projected compound annual growth rate of 9.9% from 2020 to 2027. I have not seen national sales numbers since this July report, but we have noticed a large increase in online sales for the doctors using my Skin Type Solutions System. This is most likely because, in a national crisis, the self-care and beauty business segments often see growth. So as you can see, dermatologist-dispensed skin care is becoming a major player in national skin care sales. Let’s get back to the story of how this came to be the case.
Peter Elias, MD. Dr. Elias is professor in the department of dermatology at the University of California, San Francisco. In 1996, Dr. Elias published a landmark paper in the Journal of Investigative Dermatology demonstrating that a 1:1:1 ratio of ceramides, fatty acids, and cholesterol is required to repair a damaged skin barrier. He filed multiple patents for using these lipids in moisturizers as early as 1992. His lipid research has stood the test of time, and this paper is still frequently cited. Dr. Elias has authored over 500 peer reviewed articles on the skin barrier, has edited or coauthored three books on skin barrier science, and developed EpiCeram, a product that utilizes ceramide, the fatty acid linoleic acid, and cholesterol. EpiCeram is the only barrier repair moisturizer approved by the Food and Drug Administration and is available by prescription only.
Kathy Fields, MD, and Katie Rodan, MD. Dr. Fields and Dr. Rodan met at Stanford (Calif.) University. In the 1980s, these entrepreneurial dermatologists realized that patients did not understand the role of preventing acne rather than just treating it. As dermatologists, they knew that a consistent daily routine to prevent acne was much more effective than waiting for an outbreak and spot-treating lesions. They took an already available OTC medication – benzoyl peroxide – and educated consumers through infomercials that they needed to stay ahead of acne instead of waiting for a breakout. Using infomercials to sell skin care, selling skin care kits, and educating patients about the need to prevent acne rather than spot treat it was very unusual at the time. As we all know, reeducating your patients is a huge challenge. Dr. Fields and Dr. Rodan changed consumers thinking in a genius way that continues to resonate today by choosing a brand name to make their point: Proactiv. Their simple 3-step acne kit encouraged patients to be proactive about their acne and encouraged compliance. (Patients love exact skin care steps as demonstrated again by the success of the skin care line from plastic surgeon Suzan Obagi, MD, which became available around 1988).
Dr. Fields and Dr. Rodan first offered Proactiv to Neutrogena, which turned it down. This early disappointment did not deter them and ended up benefiting them because this gave them the idea to do infomercials. Guthy Renker agreed to market and distribute the product, and the first Proactiv infomercial appeared on TV in 1995. It quickly became popular and is still one of the best selling skin care lines of all time. It’s important to note that the “overnight success” of Proactiv took at least a decade of effort.
Dr. Rodan and Dr. Fields started a new skin care line called Rodan and Fields in 2002, which was sold in department stores. This was at a time when department stores were losing market share of the skin care business, and Dr. Rodan and Dr. Fields wisely relaunched in 2007 using a direct sales model similar to Mary Kay and Avon. Their ability to encourage and motivate their team is apparent in the enthusiasm seen in their sales consultants.
Heather Woolery Lloyd, MD. Dr. Woolery Lloyd got her medical degree at the University of Miami where she also completed her dermatology residency. Her interest in skin of color led to her appointment as director of Ethnic Skin Care at the University of Miami, the country’s first cosmetic ethnic skin care department at a major university. She spent years lecturing around the world on skin of color issues and performing clinical trials before she developed the “Specific Beauty” skin care line for melanin rich skin types. Specific Beauty was acquired by Guthy Renker and is available online. It is the most popular dermatologist developed skin care line for skin of color.
In the late 1980s and early 1990s, other dermatologists threw their hats into the ring and came out with skin care lines – some successful and some not. Unfortunately, many skin care lines at that time were based on “pseudoscience” and exaggerated claims, which fueled the fire of those who felt dermatologists should steer clear of these entrepreneurial pursuits. A debate about the ethics of doctors retailing skin care began, and the controversy led to this 2010 statement by the American Medical Association: “In-office sale of health-related products by physicians presents a financial conflict of interest, risks placing undue pressure on the patient, and threatens to erode patient trust and undermine the primary obligation of physicians to serve the interests of their patients before their own.”
Many dermatologists dropped out of the AMA as a result because they felt the organization was no longer representing dermatologist’s interests. After all, we know skin care science better than anyone, and many dermatologists were insulted by the suggestion that we would place our personal financial gain over the best interests of our patients.
This is a perfect example of how the actions of a few unscrupulous dermatologists can affect the entire specialty. I like to focus on the ethical entrepreneurial dermatologists who made great contributions to the skin care industry based on science, efficacy, and patient education and encourage the ethical among us to provide this science-based information to our patients to protect them from pseudoscience-based opportunists. It is obvious that I believe that dermatologists have a responsibility to provide medical advice on skin care to their patients. If not us, who will do it as ethically as we will? But I plead with those of you out there who are promoting foolish stem cell–containing creams and other impossible technologies to remember that you are hurting the credibility of our entire dermatology profession.
In my next column, I will discuss dermatologists who have played a significant role behind the scenes in the development of the skin care industry.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann has written two textbooks and a New York Times Best Sellers book for consumers. Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Galderma, Revance, Evolus, and Burt’s Bees. She is the CEO of Skin Type Solutions, a company that independently tests skin care products and makes recommendations to physicians on which skin care technologies are best. Write to her at [email protected].
References
Castanedo-Tardan MP, Baumann L. Clin Dermatol. Jul-Aug 2009;27(4):355-8.
Gormley DE. Arch Dermatol. 1999 Jul;135(7):765-6.
Miller RC. Arch Dermatol. 1999 Mar;135(3):255-6.
Virtual Mentor. 2010;12(12):925-7.
Dermatologists play a key role in the transformation of transgender patients
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
FROM MOA 2020