User login
Light therapy offers brighter future for scar patients
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
FDA issues alert on illegal silicone injections
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
Stem cells spark successful skin regeneration
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
FROM NATURE
VIDEO: Consider combining treatments when body sculpting
LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.
In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.
Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.
In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.
Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
LAS VEGAS – Currently, there are available treatments that are effective in contouring the body, Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Some devices can help patients looking for reductions of trouble spots, such as around the abdomen, and are safe and effective, said Dr. Zachary of the University of California, Irvine. However, they are not a realistic option for obese or overweight patients, he added.
In addition, other treatments can be combined with body sculpting devices to optimize results, particularly when removing fat in the submental area, he noted.
Dr. Zachary disclosed relationships with Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
VIDEO: Hone aesthetic technique with upper face first
LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.
, he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.
Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.
, he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.
Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – For those starting to use toxins and fillers, “my first advice is to get a good education,” Christopher B. Zachary, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Know … how to evaluate your patient, know where the problems are, know what the danger zones are, understand your anatomy,” advised Dr. Zachary of the University of California, Irvine.
, he noted. Procedures on the upper face, such as the treatment for crow’s feet or a brow lift, can be “a home run,” while the lower face is much more complicated, he said in the video interview.
Dr. Zachary disclosed relationships with companies including Solta, Zeltiq, Sciton, DUSA, Zimmer, Cutera, Alma, and Amway.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Recommending efficacious cleansers for your patients
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates
Reference
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates
Reference
Cleansing is one of the most important steps in any skin care routine, but the surfeit of products on the market can lead to patients selecting an inappropriate cleanser for their skin type. This can engender various adverse cutaneous effects, including xerosis, flaking, acne, and flare-ups of chronic skin conditions such as eczema and rosacea. For example, acne medications are better tolerated when the proper cleanser is used. Cleanser choice is particularly important for individuals with dry skin who have an impaired barrier and those with sensitive skin who are susceptible to inflammation. The following discussion focuses on the factors that practitioners should address with patients when recommending cleansing products to help them maximize their outcomes and maintain clear, healthy-looking skin.
TYPES OF CLEANSERS
Foaming agents
Anionic surface acting agents (surfactants or detergents) produce foam and display the greatest cleansing potency. (Table 1). Because these detergents remove lipids from the skin’s surface and protective bilayer membrane barrier, they should only be used only by individuals with increased sebum production. Ingredients in this category injure the skin barrier and make the skin more susceptible to irritant reactions.1 For example, the widely used compound sodium lauryl sulfate (SLS), which strips lipids from the skin, irritates the skin to such an extent that it is used in research labs to hinder the skin barrier to test “barrier repair products.” The “sulfate- free” trend originates from the irritation caused by SLS. The barrier disruption caused by SLS can be used to intentionally damage the skin barrier to allow increased penetration of chemical peeling products and other therapeutic agents. An alternative to SLS is sodium laureth sulfate (or sodium lauryl ether sulfate, also known as SLES), which exhibits foaming attributes but is less likely than SLS to cause irritation. We often use a foaming cleanser in our practice prior to injectable procedures to ensure that makeup and debris are removed from the skin, and to decrease the time needed for topical lidocaine to penetrate into the skin. If you adopt this strategy, you should follow the injectable procedure with a barrier repair moisturizer.
Nonfoaming agents
These agents were developed through efforts to reduce detergent irritancy. This class of cleansers includes superfatted soaps, combination bars (“combars”), syndet bars (composed of synthetic surfactants) and compounds that deposit lipids on the skin, such as creams, lotions and oils. Cream, milk, cold creams, and oil cleansers fall into this category. These products usually have a neutral pH, and include ingredients such as alkyl glyceryl, ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate. Organic nonfoaming agents are also available, and may include saponins, a large family of structurally related compounds derived from plant, and sucrose laurate. Nonfoaming cleansers are most appropriate for dry skin types. Oily skin types often report that they “do not feel clean” when they use these cleansers.
Hydroxy acid cleansers
Alpha hydroxy acids (AHAs) are well suited for use by individuals with dry skin because hydroxy acids act as humectants (water-soluble materials with high water absorption capabilities). These hydrophilic cleansers provide exfoliation, and are appropriate for individuals with dry skin and acne because their low pH contributes to an inhospitable microbiome for Propionibacterium acnes, making it harder for the bacteria to thrive. Importantly, the exfoliating activity imparted by hydroxy acids sets the stage for better penetration into the stratum corneum by ingredients applied subsequent to the cleanser. Alpha hydroxy acid cleansers do not dry out the skin the way that salicylic acid cleansers do because their hydrophilic nature makes them unable to penetrate through sebum.
Salicylic acid (SA) cleansers are a member of the aspirin family and therefore confer anti-inflammatory properties. Salicylic acid is lipophilic and can penetrate through the sebum derived lipids into pores. They are the most effective cleansers to unclog pores. Therefore, SA cleansers are ideal for use by individuals with oily, sensitive skin prone to acne, seborrheic dermatitis, or rosacea. The exfoliation yielded by salicylic acid also enhances skin barrier penetration by ingredients applied after its use and is well tolerated by individuals with oily skin. Dry skin types, especially those on retinoids and benzoyl peroxide, will not tolerate SA as well as they will AHA cleansers.
Antibacterial cleansers
Antibacterial cleansers contain ingredients that reduce P. acnes and other types of bacteria on the skin. These products include benzoyl peroxide (BP), silver, hypochlorous acid, and sodium hypochlorite. Benzoyl peroxide can be highly irritating and is not well tolerated by patients with dry skin. Silver has a long history, having been used as an antibacterial agent since the times of King Herod. On the other hand, hypochlorous acid and sodium hypochlorite are novel entrants in the cleansing realm, particularly for individuals with acne. In fact, sodium hypochlorite is formulated to be mild enough for daily use while still sufficiently effective for acne-prone skin.
CLEANSER CHOICE BY SKIN ISSUE
Acne
Recommending the right cleanser for acne-prone skin first depends on whether the patient has oily or dry skin. Individuals with dry skin and acne cannot tolerate drying acne medications. Choosing the correct cleanser and moisturizer can help acne patients be more compliant with the acne treatment plan because of fewer side effects. Dry skin acne types often need two different cleansers. For the morning cleanser, AHA cleansers such as glycolic acid are effective at managing dry. acne-prone skin because glycolic acid has a relatively low pH. P. acnes is less likely to grow on skin with a lower pH.
Hydroxy acids help prevent clogged pores and exfoliate dead skin, which helps prevent acne comedones. Glycolic acid also serves as a humectant ingredient. Creamy cleansers should be used once daily, preferably at night for patients who use makeup since these products are effective at makeup removal. Foaming cleansers should never be used on dry, acne-prone skin. Individuals with the acne subtype of sensitive skin should avoid using scrubs, loofahs, and other forms of mechanical exfoliation.
Patients with oily skin and acne are easier to treat than are dry types because they can better tolerate acne medications. I recommend a salicylic acid cleanser in the morning to unclog pores. The anti-inflammatory properties of salicylic acid help prevent the formation of papules and pustules that characterize acne. Twice-daily use of salicylic acid by patients with oily skin and acne may feel too drying when combined with acne medications such as a retinoid and benzoyl peroxide. If this is the case, a foaming cleanser can be used in the evening to remove dirt, makeup, sunscreen, and debris that can clog pores and exacerbate acne.
Rosacea
Most dry skin type rosacea patients flush red when they wash their face, even if they only use water. The friction alone is enough to cause them to react. Rosacea patients can skip the morning cleanse to help reduce this skin irritation and flushing. Instead they should apply their a.m. anti-redness products followed by a sunscreen appropriate for their skin type. In the evening, a soothing, nonfoaming cleanser with anti-inflammatory ingredients is the best choice to remove makeup, sunscreen, and any built-up dirt or bacteria from the skin’s surface. This should be followed by an anti-redness product that targets the inflammation caused by rosacea.
Anti-inflammatory ingredients that can be found in soothing cleansers and moisturizers for rosacea prone skin include argan oil, green tea, feverfew, chamomile, licorice extract, and aloe.
Patients with very oily skin who have rosacea need to cleanse twice daily to remove excess oil to prevent comedones and acne lesions. A foaming cleanser that contains anti-inflammatory ingredients such as green tea, feverfew, licorice extract, aloe, niacinamide, green tea, and salicylic acid are a good choice for oily rosacea prone skin types.
All rosacea patients should be counseled to avoid mechanical exfoliation, including cleansing scrubs, chemical exfoliants, and abrasive loofahs or cloths.
Eczema
Patients with eczema should choose the same nonfoaming cleansers recommended for dry skin. For patients with frequent skin infections, hypochlorite and silver are beneficial ingredients found in cleansers to help decrease skin bacteria and prevent infections. Foaming cleansers should never be used in eczema prone types.
Conclusion
Cleansers play an important role in skin care because they affect the skin barrier, pH of the skin, presence of bacteria, condition of the pores, and penetration of the post cleanser–applied ingredients. Knowing which cleansing product to use based on a patient’s skin type is critical to recommending the proper ingredients so that patients can achieve and maintain healthy skin.
Table 1. Ingredients used in foaming cleansers
Acyl glycinates
Acylglutamates
Alkyl acyl isethionates
Alkyl carboxylates
Alkyl ether sulfates
Alkyl ethoxy sulfates
Alkyl phosphates
Alkyl sulfates
Alkyl sulfonates
Alkyl sulfosuccinates
Alkyl taurates
Reference
Barnacles that come with wisdom
One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”
The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.1
Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.3
Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO2 laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.4
SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].
References:
1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf
2: Am J Dermatopathol. 2014 Aug;36(8):635-42.
3: Indian J Dermatol. 2013 Jul;58(4):326.
4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..
One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”
The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.1
Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.3
Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO2 laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.4
SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].
References:
1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf
2: Am J Dermatopathol. 2014 Aug;36(8):635-42.
3: Indian J Dermatol. 2013 Jul;58(4):326.
4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..
One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”
The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.1
Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.3
Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO2 laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.4
SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].
References:
1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf
2: Am J Dermatopathol. 2014 Aug;36(8):635-42.
3: Indian J Dermatol. 2013 Jul;58(4):326.
4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..
VIDEO: Light-based scar treatments improve more than just cosmetic appearance
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
LAS VEGAS – Clinicians can offer patients with scarring the potential for more comprehensive improvement thanks to progress in light-based devices and technologies, Kristen M. Kelly, MD, said in a video interview at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
“Not only can we improve these scars from a cosmetic appearance ... but we can also greatly improve the symptoms that patients have,” such as scar-related stinging, discomfort, and movement restrictions or contractures, said Dr. Kelly of the University of California, Irvine.
In addition, combining light-based therapies with medications applied after the treatments can optimize results, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron-Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT SDEF LAS VEGAS DERMATOLOGY SEMINAR
Review of plant phenolics, part 3: Nonflavonoid compounds
Polyphenols are widely distributed in the plant kingdom, and are found in copious supply in multiple vegetables, fruits, herbs, grains, tea, coffee beans, honey, and red wine, for example. They are an especially important source of antioxidants and are increasingly the focus of research due to their potent and diverse biologic activities. In the conclusion to my three-part review of polyphenols, this column identifies representative compounds from the classes of nonflavonoid polyphenols and provides a brief update on research.
Phenolic acids: ferulic acid
Derived from curcumin, ferulic acid is noted for exhibiting multiple biologic activities, including antiapoptotic, anticarcinogenic, antidiabetic, hepatoprotective, and cardioprotective, among others. Its beneficial effects are thought to be mediated through its antioxidant and anti-inflammatory characteristics.1 In a small 2008 study, a stable formulation of 15% l-ascorbic acid, 1% alpha-tocopherol, and 0.5% ferulic acid was applied topically to normal-appearing human skin for 4 days and was found to impart significant photoprotection against solar-simulated UV radiation and was especially effective at diminishing thymine dimer mutations, which are linked to skin cancer. The authors also noted that the mechanism of action of this antioxidant formulation differs from that of sunscreens and, therefore, may serve as a supplement to such products.2 (It is worth noting that ferulic acid has been approved as a sunscreen agent in Japan.3)
In 2015, Ambothi et al. used Swiss albino mice to assess the photochemopreventive effects of ferulic acid against chronic (30-week) UVB, finding the intraperitoneal and topical administration of the phenolic acid effective in significantly lowering the incidence of UVB-induced tumor volume and weight in the mice skin.4 The next year, Hahn et al. reported that pretreatment with ferulic acid protects human dermal fibroblasts from UVA-induced photodamage.5 Also in 2016, Chaiprasongsuk et al. found that several dietary phenolics, including ferulic acid, deliver protection against UVA-induced melanogenesis through indirect regulation of the Nrf2-ARE pathway.6 
Lignans: flaxseed
Flaxseed lignans, which exhibit a wide range of biologic activities, are best known for their antioxidant properties.7 In a 2017 study using atopic dermatitis–induced NC/Nga mice, Yang et al. found that fermented flaxseed oil administered orally was successful in relieving symptoms such as erythema, edema, pruritus, and epithelial damage.8 Two years earlier, Draganescu et al. developed a topical flaxseed extract formulation that displayed wound healing capabilities on Wistar rats.7 Emulsions produced from the oils and seeds of transgenic flax have also been found to protect against oxidative stress in hamster fibroblasts, with investigators suggesting that the emulsions have potential to protect the skin against such damage.8
Stilbenes: resveratrol
The antioxidant potency of resveratrol has been cited for conferring a wide range of salutary effects, including antitumorigenic as well as antiaging activity. In 2008, a resveratrol-based skin care formulation intended to combat photoaging was reported to exhibit 17-fold greater antioxidant activity than idebenone.9 In a different study that year, resveratrol, the primary active polyphenolic constituent in red wine, was assessed in terms of topical/transdermal delivery viability, given previously established benefits shown via systemic administration. Several hydrogel systems used as resveratrol vehicles were shown to be safe and effective methods for cutaneously delivering the therapeutic effects of this antioxidant.10 Since then, resveratrol has been demonstrated to penetrate the skin via topical administration, reinforcing the antioxidant system of the stratum corneum and delivering increases of antioxidants to human epidermal tissue.11
In 2014, Farris et al. showed that a proprietary topical antioxidant blend of resveratrol, baicalin, and vitamin E applied topically at night yielded statistically significant amelioration of fine lines and wrinkles, as well as skin firmness, elasticity, laxity, hyperpigmentation, radiance, and roughness over a 12-week period.12 Resveratrol has also been shown in mice to suppress the inflammatory response and improve survival from severe burns with bacterial infections.13 
Hydrolyzable tannins: ellagic acid
Ellagic acid, a dimer of gallic acid, has been reported to impart anti-inflammatory, antitumor, immunomodulatory, and antifungal activities.14-16 Ortiz-Ruiz et al. have noted that while ellagic acid is used as a whitening agent, it can act as a substrate to rather than an inhibitor of tyrosinase, as it is oxidized by the enzyme to an unstable o-quinone. However, as a potent antioxidant, ellagic acid can block melanogenesis by reducing o-quinones and semiquinones.17
In a double-blind, placebo-controlled, 4-week trial to assess the effects of orally administered ellagic acid–rich pomegranate extract on the pigmentation of 13 women after UV exposure, with healthy volunteers randomly assigned to high-dose, low-dose, and control groups, luminance values decreased by 1.73% in the high-dose group and 1.35% in the low-dose group, as compared with the control group, and stains and freckles were reported to be diminished.18 A 2016 study in human dermal fibroblasts by Baek et al. suggested that ellagic acid displays antiphotoaging activity, as the polyphenol protected against UVB-induced oxidative stress potentially through an Nrf2-dependent pathway.15
Condensed tannins (Proanthocyanidins): pycnogenol
Pycnogenol has been used in an antioxidant mixture also including vitamins C and E, as well as evening primrose that when orally administered for 10 weeks to female SKH-1 hairless mice exposed three times weekly to UVB irradiation demonstrated the capacity to significantly inhibit wrinkle formation by markedly suppressing UVB-induced MMP activity while promoting collagen production.19 In a 2012 study of 112 women with mild to moderate photoaging, orally administered pycnogenol was shown to yield significant reductions in clinical grading of skin photoaging scores.20 Four years later, a review by Grether-Beck et al. suggested that oral administration of pycnogenol imparts photoprotection, diminishes hyperpigmentation, and improves skin barrier function and the stability of the extracellular matrix.21
Lignins: various woody plants
Recognized as efficient natural scavengers of reactive oxygen species, lignins are complex phenolic polymers that are abundant in nature, particularly in various tree species and agricultural products. In 2004, Dizhbite et al. isolated lignin samples from deciduous and coniferous trees to assess their capacity as natural antioxidants. Samples were assessed against the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical in homogeneous conditions, with the commercially available kraft lignin noted for displaying antibacterial activity associated with its radical-scavenging properties.22 Four years later, Ugartondo et al. studied several lignins and reported a strong antioxidant capacity at various concentrations that were innocuous to normal human cells and stable when exposed to UVA. The investigators concluded that lignins may be viable for inclusion in cosmetic and topical medical formulations.23
Conclusion
A brief survey of the polyphenolic landscape obviously cannot do the subject justice. From the dermatologic perspective, this diverse family of compounds factor into the skin care formulations becoming more prevalent in the established armamentarium, as well as the direct-to-consumer market. Given the increasing attention paid here and elsewhere to the impact of diet on the skin, the status of this dynamic class of polyphenolic compounds, which includes several antioxidants and is found in numerous plants, appears to be well deserved and warrants much more research.
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 wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Food Chem Toxicol. 2017 May;103:41-55.
2. J Am Acad Dermatol. 2008 Sep;59(3):418-25.
3. J Pharm Biomed Anal. 2008 Mar 13;46(4):645-52.
4. Food Chem Toxicol. 2015 Aug;82:72-8.
5. Ann Dermatol. 2016 Dec;28(6):740-8.
6. Redox Biol. 2016 Aug;8:79-90.
7. Int J Biol Macromol. 2015 Jan;72:614-23.
8. Evid Based Complement Alternat Med. 2017;2017:5469125.
9. J Cosmet Dermatol. 2008 Mar;7(1):2-7.
10. Biol Pharm Bull. 2008 May;31(5):955-62.
11. Arch Dermatol Res. 2017 Aug;309(6):423-31.
12. J Drugs Dermatol. 2014 Dec;13(12):1467-72.
13. Inflammation. 2015;38(3):1273-80.
14. Dermatol Ther. 2012 May-Jun;25(3):252-9.
15. Korean J Physiol Pharmacol. 2016 May;20(3):269-77.
16. Phytother Res. 2015 Jul;29(7):1019-25.
17. J Dermatol Sci. 2016 May;82(2):115-22.
18. J Nutr Sci Vitaminol (Tokyo). 2006 Oct;52(5):383-8.
19. Photodermatol Photoimmunol Photomed. 2007 Oct;23(5):155-62.
20. Clin Interv Aging. 2012;7:275-86.
21. Skin Pharmacol Physiol. 2016;29(1):13-7.
22. Bioresour Technol. 2004 Dec;95(3):309-17.
23. Bioresour Technol. 2008 Sep;99(14):6683-7.
Polyphenols are widely distributed in the plant kingdom, and are found in copious supply in multiple vegetables, fruits, herbs, grains, tea, coffee beans, honey, and red wine, for example. They are an especially important source of antioxidants and are increasingly the focus of research due to their potent and diverse biologic activities. In the conclusion to my three-part review of polyphenols, this column identifies representative compounds from the classes of nonflavonoid polyphenols and provides a brief update on research.
Phenolic acids: ferulic acid
Derived from curcumin, ferulic acid is noted for exhibiting multiple biologic activities, including antiapoptotic, anticarcinogenic, antidiabetic, hepatoprotective, and cardioprotective, among others. Its beneficial effects are thought to be mediated through its antioxidant and anti-inflammatory characteristics.1 In a small 2008 study, a stable formulation of 15% l-ascorbic acid, 1% alpha-tocopherol, and 0.5% ferulic acid was applied topically to normal-appearing human skin for 4 days and was found to impart significant photoprotection against solar-simulated UV radiation and was especially effective at diminishing thymine dimer mutations, which are linked to skin cancer. The authors also noted that the mechanism of action of this antioxidant formulation differs from that of sunscreens and, therefore, may serve as a supplement to such products.2 (It is worth noting that ferulic acid has been approved as a sunscreen agent in Japan.3)
In 2015, Ambothi et al. used Swiss albino mice to assess the photochemopreventive effects of ferulic acid against chronic (30-week) UVB, finding the intraperitoneal and topical administration of the phenolic acid effective in significantly lowering the incidence of UVB-induced tumor volume and weight in the mice skin.4 The next year, Hahn et al. reported that pretreatment with ferulic acid protects human dermal fibroblasts from UVA-induced photodamage.5 Also in 2016, Chaiprasongsuk et al. found that several dietary phenolics, including ferulic acid, deliver protection against UVA-induced melanogenesis through indirect regulation of the Nrf2-ARE pathway.6
Lignans: flaxseed
Flaxseed lignans, which exhibit a wide range of biologic activities, are best known for their antioxidant properties.7 In a 2017 study using atopic dermatitis–induced NC/Nga mice, Yang et al. found that fermented flaxseed oil administered orally was successful in relieving symptoms such as erythema, edema, pruritus, and epithelial damage.8 Two years earlier, Draganescu et al. developed a topical flaxseed extract formulation that displayed wound healing capabilities on Wistar rats.7 Emulsions produced from the oils and seeds of transgenic flax have also been found to protect against oxidative stress in hamster fibroblasts, with investigators suggesting that the emulsions have potential to protect the skin against such damage.8
Stilbenes: resveratrol
The antioxidant potency of resveratrol has been cited for conferring a wide range of salutary effects, including antitumorigenic as well as antiaging activity. In 2008, a resveratrol-based skin care formulation intended to combat photoaging was reported to exhibit 17-fold greater antioxidant activity than idebenone.9 In a different study that year, resveratrol, the primary active polyphenolic constituent in red wine, was assessed in terms of topical/transdermal delivery viability, given previously established benefits shown via systemic administration. Several hydrogel systems used as resveratrol vehicles were shown to be safe and effective methods for cutaneously delivering the therapeutic effects of this antioxidant.10 Since then, resveratrol has been demonstrated to penetrate the skin via topical administration, reinforcing the antioxidant system of the stratum corneum and delivering increases of antioxidants to human epidermal tissue.11
In 2014, Farris et al. showed that a proprietary topical antioxidant blend of resveratrol, baicalin, and vitamin E applied topically at night yielded statistically significant amelioration of fine lines and wrinkles, as well as skin firmness, elasticity, laxity, hyperpigmentation, radiance, and roughness over a 12-week period.12 Resveratrol has also been shown in mice to suppress the inflammatory response and improve survival from severe burns with bacterial infections.13
Hydrolyzable tannins: ellagic acid
Ellagic acid, a dimer of gallic acid, has been reported to impart anti-inflammatory, antitumor, immunomodulatory, and antifungal activities.14-16 Ortiz-Ruiz et al. have noted that while ellagic acid is used as a whitening agent, it can act as a substrate to rather than an inhibitor of tyrosinase, as it is oxidized by the enzyme to an unstable o-quinone. However, as a potent antioxidant, ellagic acid can block melanogenesis by reducing o-quinones and semiquinones.17
In a double-blind, placebo-controlled, 4-week trial to assess the effects of orally administered ellagic acid–rich pomegranate extract on the pigmentation of 13 women after UV exposure, with healthy volunteers randomly assigned to high-dose, low-dose, and control groups, luminance values decreased by 1.73% in the high-dose group and 1.35% in the low-dose group, as compared with the control group, and stains and freckles were reported to be diminished.18 A 2016 study in human dermal fibroblasts by Baek et al. suggested that ellagic acid displays antiphotoaging activity, as the polyphenol protected against UVB-induced oxidative stress potentially through an Nrf2-dependent pathway.15
Condensed tannins (Proanthocyanidins): pycnogenol
Pycnogenol has been used in an antioxidant mixture also including vitamins C and E, as well as evening primrose that when orally administered for 10 weeks to female SKH-1 hairless mice exposed three times weekly to UVB irradiation demonstrated the capacity to significantly inhibit wrinkle formation by markedly suppressing UVB-induced MMP activity while promoting collagen production.19 In a 2012 study of 112 women with mild to moderate photoaging, orally administered pycnogenol was shown to yield significant reductions in clinical grading of skin photoaging scores.20 Four years later, a review by Grether-Beck et al. suggested that oral administration of pycnogenol imparts photoprotection, diminishes hyperpigmentation, and improves skin barrier function and the stability of the extracellular matrix.21
Lignins: various woody plants
Recognized as efficient natural scavengers of reactive oxygen species, lignins are complex phenolic polymers that are abundant in nature, particularly in various tree species and agricultural products. In 2004, Dizhbite et al. isolated lignin samples from deciduous and coniferous trees to assess their capacity as natural antioxidants. Samples were assessed against the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical in homogeneous conditions, with the commercially available kraft lignin noted for displaying antibacterial activity associated with its radical-scavenging properties.22 Four years later, Ugartondo et al. studied several lignins and reported a strong antioxidant capacity at various concentrations that were innocuous to normal human cells and stable when exposed to UVA. The investigators concluded that lignins may be viable for inclusion in cosmetic and topical medical formulations.23
Conclusion
A brief survey of the polyphenolic landscape obviously cannot do the subject justice. From the dermatologic perspective, this diverse family of compounds factor into the skin care formulations becoming more prevalent in the established armamentarium, as well as the direct-to-consumer market. Given the increasing attention paid here and elsewhere to the impact of diet on the skin, the status of this dynamic class of polyphenolic compounds, which includes several antioxidants and is found in numerous plants, appears to be well deserved and warrants much more research.
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 wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Food Chem Toxicol. 2017 May;103:41-55.
2. J Am Acad Dermatol. 2008 Sep;59(3):418-25.
3. J Pharm Biomed Anal. 2008 Mar 13;46(4):645-52.
4. Food Chem Toxicol. 2015 Aug;82:72-8.
5. Ann Dermatol. 2016 Dec;28(6):740-8.
6. Redox Biol. 2016 Aug;8:79-90.
7. Int J Biol Macromol. 2015 Jan;72:614-23.
8. Evid Based Complement Alternat Med. 2017;2017:5469125.
9. J Cosmet Dermatol. 2008 Mar;7(1):2-7.
10. Biol Pharm Bull. 2008 May;31(5):955-62.
11. Arch Dermatol Res. 2017 Aug;309(6):423-31.
12. J Drugs Dermatol. 2014 Dec;13(12):1467-72.
13. Inflammation. 2015;38(3):1273-80.
14. Dermatol Ther. 2012 May-Jun;25(3):252-9.
15. Korean J Physiol Pharmacol. 2016 May;20(3):269-77.
16. Phytother Res. 2015 Jul;29(7):1019-25.
17. J Dermatol Sci. 2016 May;82(2):115-22.
18. J Nutr Sci Vitaminol (Tokyo). 2006 Oct;52(5):383-8.
19. Photodermatol Photoimmunol Photomed. 2007 Oct;23(5):155-62.
20. Clin Interv Aging. 2012;7:275-86.
21. Skin Pharmacol Physiol. 2016;29(1):13-7.
22. Bioresour Technol. 2004 Dec;95(3):309-17.
23. Bioresour Technol. 2008 Sep;99(14):6683-7.
Polyphenols are widely distributed in the plant kingdom, and are found in copious supply in multiple vegetables, fruits, herbs, grains, tea, coffee beans, honey, and red wine, for example. They are an especially important source of antioxidants and are increasingly the focus of research due to their potent and diverse biologic activities. In the conclusion to my three-part review of polyphenols, this column identifies representative compounds from the classes of nonflavonoid polyphenols and provides a brief update on research.
Phenolic acids: ferulic acid
Derived from curcumin, ferulic acid is noted for exhibiting multiple biologic activities, including antiapoptotic, anticarcinogenic, antidiabetic, hepatoprotective, and cardioprotective, among others. Its beneficial effects are thought to be mediated through its antioxidant and anti-inflammatory characteristics.1 In a small 2008 study, a stable formulation of 15% l-ascorbic acid, 1% alpha-tocopherol, and 0.5% ferulic acid was applied topically to normal-appearing human skin for 4 days and was found to impart significant photoprotection against solar-simulated UV radiation and was especially effective at diminishing thymine dimer mutations, which are linked to skin cancer. The authors also noted that the mechanism of action of this antioxidant formulation differs from that of sunscreens and, therefore, may serve as a supplement to such products.2 (It is worth noting that ferulic acid has been approved as a sunscreen agent in Japan.3)
In 2015, Ambothi et al. used Swiss albino mice to assess the photochemopreventive effects of ferulic acid against chronic (30-week) UVB, finding the intraperitoneal and topical administration of the phenolic acid effective in significantly lowering the incidence of UVB-induced tumor volume and weight in the mice skin.4 The next year, Hahn et al. reported that pretreatment with ferulic acid protects human dermal fibroblasts from UVA-induced photodamage.5 Also in 2016, Chaiprasongsuk et al. found that several dietary phenolics, including ferulic acid, deliver protection against UVA-induced melanogenesis through indirect regulation of the Nrf2-ARE pathway.6
Lignans: flaxseed
Flaxseed lignans, which exhibit a wide range of biologic activities, are best known for their antioxidant properties.7 In a 2017 study using atopic dermatitis–induced NC/Nga mice, Yang et al. found that fermented flaxseed oil administered orally was successful in relieving symptoms such as erythema, edema, pruritus, and epithelial damage.8 Two years earlier, Draganescu et al. developed a topical flaxseed extract formulation that displayed wound healing capabilities on Wistar rats.7 Emulsions produced from the oils and seeds of transgenic flax have also been found to protect against oxidative stress in hamster fibroblasts, with investigators suggesting that the emulsions have potential to protect the skin against such damage.8
Stilbenes: resveratrol
The antioxidant potency of resveratrol has been cited for conferring a wide range of salutary effects, including antitumorigenic as well as antiaging activity. In 2008, a resveratrol-based skin care formulation intended to combat photoaging was reported to exhibit 17-fold greater antioxidant activity than idebenone.9 In a different study that year, resveratrol, the primary active polyphenolic constituent in red wine, was assessed in terms of topical/transdermal delivery viability, given previously established benefits shown via systemic administration. Several hydrogel systems used as resveratrol vehicles were shown to be safe and effective methods for cutaneously delivering the therapeutic effects of this antioxidant.10 Since then, resveratrol has been demonstrated to penetrate the skin via topical administration, reinforcing the antioxidant system of the stratum corneum and delivering increases of antioxidants to human epidermal tissue.11
In 2014, Farris et al. showed that a proprietary topical antioxidant blend of resveratrol, baicalin, and vitamin E applied topically at night yielded statistically significant amelioration of fine lines and wrinkles, as well as skin firmness, elasticity, laxity, hyperpigmentation, radiance, and roughness over a 12-week period.12 Resveratrol has also been shown in mice to suppress the inflammatory response and improve survival from severe burns with bacterial infections.13
Hydrolyzable tannins: ellagic acid
Ellagic acid, a dimer of gallic acid, has been reported to impart anti-inflammatory, antitumor, immunomodulatory, and antifungal activities.14-16 Ortiz-Ruiz et al. have noted that while ellagic acid is used as a whitening agent, it can act as a substrate to rather than an inhibitor of tyrosinase, as it is oxidized by the enzyme to an unstable o-quinone. However, as a potent antioxidant, ellagic acid can block melanogenesis by reducing o-quinones and semiquinones.17
In a double-blind, placebo-controlled, 4-week trial to assess the effects of orally administered ellagic acid–rich pomegranate extract on the pigmentation of 13 women after UV exposure, with healthy volunteers randomly assigned to high-dose, low-dose, and control groups, luminance values decreased by 1.73% in the high-dose group and 1.35% in the low-dose group, as compared with the control group, and stains and freckles were reported to be diminished.18 A 2016 study in human dermal fibroblasts by Baek et al. suggested that ellagic acid displays antiphotoaging activity, as the polyphenol protected against UVB-induced oxidative stress potentially through an Nrf2-dependent pathway.15
Condensed tannins (Proanthocyanidins): pycnogenol
Pycnogenol has been used in an antioxidant mixture also including vitamins C and E, as well as evening primrose that when orally administered for 10 weeks to female SKH-1 hairless mice exposed three times weekly to UVB irradiation demonstrated the capacity to significantly inhibit wrinkle formation by markedly suppressing UVB-induced MMP activity while promoting collagen production.19 In a 2012 study of 112 women with mild to moderate photoaging, orally administered pycnogenol was shown to yield significant reductions in clinical grading of skin photoaging scores.20 Four years later, a review by Grether-Beck et al. suggested that oral administration of pycnogenol imparts photoprotection, diminishes hyperpigmentation, and improves skin barrier function and the stability of the extracellular matrix.21
Lignins: various woody plants
Recognized as efficient natural scavengers of reactive oxygen species, lignins are complex phenolic polymers that are abundant in nature, particularly in various tree species and agricultural products. In 2004, Dizhbite et al. isolated lignin samples from deciduous and coniferous trees to assess their capacity as natural antioxidants. Samples were assessed against the 1,1-diphenyl-2-picrylhydrazyl (DPPH) radical in homogeneous conditions, with the commercially available kraft lignin noted for displaying antibacterial activity associated with its radical-scavenging properties.22 Four years later, Ugartondo et al. studied several lignins and reported a strong antioxidant capacity at various concentrations that were innocuous to normal human cells and stable when exposed to UVA. The investigators concluded that lignins may be viable for inclusion in cosmetic and topical medical formulations.23
Conclusion
A brief survey of the polyphenolic landscape obviously cannot do the subject justice. From the dermatologic perspective, this diverse family of compounds factor into the skin care formulations becoming more prevalent in the established armamentarium, as well as the direct-to-consumer market. Given the increasing attention paid here and elsewhere to the impact of diet on the skin, the status of this dynamic class of polyphenolic compounds, which includes several antioxidants and is found in numerous plants, appears to be well deserved and warrants much more research.
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 wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
References
1. Food Chem Toxicol. 2017 May;103:41-55.
2. J Am Acad Dermatol. 2008 Sep;59(3):418-25.
3. J Pharm Biomed Anal. 2008 Mar 13;46(4):645-52.
4. Food Chem Toxicol. 2015 Aug;82:72-8.
5. Ann Dermatol. 2016 Dec;28(6):740-8.
6. Redox Biol. 2016 Aug;8:79-90.
7. Int J Biol Macromol. 2015 Jan;72:614-23.
8. Evid Based Complement Alternat Med. 2017;2017:5469125.
9. J Cosmet Dermatol. 2008 Mar;7(1):2-7.
10. Biol Pharm Bull. 2008 May;31(5):955-62.
11. Arch Dermatol Res. 2017 Aug;309(6):423-31.
12. J Drugs Dermatol. 2014 Dec;13(12):1467-72.
13. Inflammation. 2015;38(3):1273-80.
14. Dermatol Ther. 2012 May-Jun;25(3):252-9.
15. Korean J Physiol Pharmacol. 2016 May;20(3):269-77.
16. Phytother Res. 2015 Jul;29(7):1019-25.
17. J Dermatol Sci. 2016 May;82(2):115-22.
18. J Nutr Sci Vitaminol (Tokyo). 2006 Oct;52(5):383-8.
19. Photodermatol Photoimmunol Photomed. 2007 Oct;23(5):155-62.
20. Clin Interv Aging. 2012;7:275-86.
21. Skin Pharmacol Physiol. 2016;29(1):13-7.
22. Bioresour Technol. 2004 Dec;95(3):309-17.
23. Bioresour Technol. 2008 Sep;99(14):6683-7.
Cosmetic Corner: Dermatologists Weigh in on Men’s Moisturizers
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s moisturizers. Consideration must be given to:
- Clinique For Men Oil Control Mattifying Moisturizer
Clinique Laboratories, LLC
“I recommend this product for men with oily or combination skin. It’s very lightweight and provides good hydration benefits without leaving the skin shiny.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Moisture Treatment for Men
Kiehl’s
“I commonly recommend this moisturizer. The Facial Fuel line is great for most skin types and the products are moderately priced.”—Gary Goldenberg, MD, New York, New York
- Neutrogena Men Triple Protect Face Lotion With Sunscreen
Johnson & Johnson Consumer Inc
“This is a light, daily moisturizer with broad-spectrum UV protection.”—Shari Lipner, MD, PhD, New York, New York
- Triple Lipid Restore 2:4:2
SkinCeuticals
“This moisturizer has the precise lipid content needed by the skin.”— Jerome Potozkin, MD, Danville, California
Cutis invites readers to send us their recommendations. Wet skin moisturizer, lip plumper, and pigment corrector will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s moisturizers. Consideration must be given to:
- Clinique For Men Oil Control Mattifying Moisturizer
Clinique Laboratories, LLC
“I recommend this product for men with oily or combination skin. It’s very lightweight and provides good hydration benefits without leaving the skin shiny.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Moisture Treatment for Men
Kiehl’s
“I commonly recommend this moisturizer. The Facial Fuel line is great for most skin types and the products are moderately priced.”—Gary Goldenberg, MD, New York, New York
- Neutrogena Men Triple Protect Face Lotion With Sunscreen
Johnson & Johnson Consumer Inc
“This is a light, daily moisturizer with broad-spectrum UV protection.”—Shari Lipner, MD, PhD, New York, New York
- Triple Lipid Restore 2:4:2
SkinCeuticals
“This moisturizer has the precise lipid content needed by the skin.”— Jerome Potozkin, MD, Danville, California
Cutis invites readers to send us their recommendations. Wet skin moisturizer, lip plumper, and pigment corrector will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
To improve patient care and outcomes, leading dermatologists offered their recommendations on men’s moisturizers. Consideration must be given to:
- Clinique For Men Oil Control Mattifying Moisturizer
Clinique Laboratories, LLC
“I recommend this product for men with oily or combination skin. It’s very lightweight and provides good hydration benefits without leaving the skin shiny.”—Jeannette Graf, MD, Great Neck, New York
- Facial Fuel Energizing Moisture Treatment for Men
Kiehl’s
“I commonly recommend this moisturizer. The Facial Fuel line is great for most skin types and the products are moderately priced.”—Gary Goldenberg, MD, New York, New York
- Neutrogena Men Triple Protect Face Lotion With Sunscreen
Johnson & Johnson Consumer Inc
“This is a light, daily moisturizer with broad-spectrum UV protection.”—Shari Lipner, MD, PhD, New York, New York
- Triple Lipid Restore 2:4:2
SkinCeuticals
“This moisturizer has the precise lipid content needed by the skin.”— Jerome Potozkin, MD, Danville, California
Cutis invites readers to send us their recommendations. Wet skin moisturizer, lip plumper, and pigment corrector will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to the Editorial Office.
Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc. and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc. endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.
