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Adalimumab enhances primary wound closure after HS surgery
, a pilot study suggests.
“Our experience suggests that under the effects of treatment with adalimumab, wound healing disorders with primary wound closure occur less often. And primary wound closure offers advantages over secondary wound healing: shorter length of inpatient stay, lower morbidity, fewer functional problems, and better quality of life,” Gefion Girbig, MD, said at the annual congress of the European Academy of Dermatology and Venereology.
She noted that primary wound closure following surgery for HS is controversial. For example, current German guidelines recommend complete surgical excision of HS lesions, followed by secondary wound healing; the guidelines advise against primary wound closure. But those guidelines were issued back in 2012, years before adalimumab (Humira) achieved regulatory approval as the first and to date only medication indicated for treatment of HS.
Experts agree that while adalimumab has been a difference maker for many patients with HS, surgery is still often necessary. And many surgeons prefer secondary wound healing in HS. That’s because healing by first intention has historically often resulted in complications involving wound healing disorders and infection. These complications necessitate loosening of the primary closure to permit further wound healing by second intention, with a resultant prolonged healing time, explained Dr. Girbig, of the Institute for Health Sciences Research in Dermatology and Nursing at University Medical Center Hamburg-Eppendorf (Germany).
She and her coinvestigators hypothesized that the disordered wound healing is a consequence of the underlying inflammatory disease that lies at the core of HS, and that quelling the inflammation with adalimumab for at least 6 months before performing surgery with primary closure while the anti-TNF therapy continues would reduce the incidence of wound healing disorders.
This was borne out in the group’s small observational pilot study. It included 10 patients with HS who underwent surgery only after at least 6 months on adalimumab. Six had surgery for axillary HS and four for inguinal disease. Only 2 of the 10 developed a wound healing disorder. Both had surgical reconstruction in the inguinal area. Neither case involved infection. Surgical management entailed opening part of the suture to allow simultaneous secondary wound closure.
This 20% incidence of disordered wound healing when primary closure was carried out while systemic inflammation was controlled via adalimumab is markedly lower than rates reported using primary closure without adalimumab. Dr. Girbig and her coinvestigators are now conducting a larger controlled study to confirm their findings.
She reported having no financial conflicts regarding her study.
, a pilot study suggests.
“Our experience suggests that under the effects of treatment with adalimumab, wound healing disorders with primary wound closure occur less often. And primary wound closure offers advantages over secondary wound healing: shorter length of inpatient stay, lower morbidity, fewer functional problems, and better quality of life,” Gefion Girbig, MD, said at the annual congress of the European Academy of Dermatology and Venereology.
She noted that primary wound closure following surgery for HS is controversial. For example, current German guidelines recommend complete surgical excision of HS lesions, followed by secondary wound healing; the guidelines advise against primary wound closure. But those guidelines were issued back in 2012, years before adalimumab (Humira) achieved regulatory approval as the first and to date only medication indicated for treatment of HS.
Experts agree that while adalimumab has been a difference maker for many patients with HS, surgery is still often necessary. And many surgeons prefer secondary wound healing in HS. That’s because healing by first intention has historically often resulted in complications involving wound healing disorders and infection. These complications necessitate loosening of the primary closure to permit further wound healing by second intention, with a resultant prolonged healing time, explained Dr. Girbig, of the Institute for Health Sciences Research in Dermatology and Nursing at University Medical Center Hamburg-Eppendorf (Germany).
She and her coinvestigators hypothesized that the disordered wound healing is a consequence of the underlying inflammatory disease that lies at the core of HS, and that quelling the inflammation with adalimumab for at least 6 months before performing surgery with primary closure while the anti-TNF therapy continues would reduce the incidence of wound healing disorders.
This was borne out in the group’s small observational pilot study. It included 10 patients with HS who underwent surgery only after at least 6 months on adalimumab. Six had surgery for axillary HS and four for inguinal disease. Only 2 of the 10 developed a wound healing disorder. Both had surgical reconstruction in the inguinal area. Neither case involved infection. Surgical management entailed opening part of the suture to allow simultaneous secondary wound closure.
This 20% incidence of disordered wound healing when primary closure was carried out while systemic inflammation was controlled via adalimumab is markedly lower than rates reported using primary closure without adalimumab. Dr. Girbig and her coinvestigators are now conducting a larger controlled study to confirm their findings.
She reported having no financial conflicts regarding her study.
, a pilot study suggests.
“Our experience suggests that under the effects of treatment with adalimumab, wound healing disorders with primary wound closure occur less often. And primary wound closure offers advantages over secondary wound healing: shorter length of inpatient stay, lower morbidity, fewer functional problems, and better quality of life,” Gefion Girbig, MD, said at the annual congress of the European Academy of Dermatology and Venereology.
She noted that primary wound closure following surgery for HS is controversial. For example, current German guidelines recommend complete surgical excision of HS lesions, followed by secondary wound healing; the guidelines advise against primary wound closure. But those guidelines were issued back in 2012, years before adalimumab (Humira) achieved regulatory approval as the first and to date only medication indicated for treatment of HS.
Experts agree that while adalimumab has been a difference maker for many patients with HS, surgery is still often necessary. And many surgeons prefer secondary wound healing in HS. That’s because healing by first intention has historically often resulted in complications involving wound healing disorders and infection. These complications necessitate loosening of the primary closure to permit further wound healing by second intention, with a resultant prolonged healing time, explained Dr. Girbig, of the Institute for Health Sciences Research in Dermatology and Nursing at University Medical Center Hamburg-Eppendorf (Germany).
She and her coinvestigators hypothesized that the disordered wound healing is a consequence of the underlying inflammatory disease that lies at the core of HS, and that quelling the inflammation with adalimumab for at least 6 months before performing surgery with primary closure while the anti-TNF therapy continues would reduce the incidence of wound healing disorders.
This was borne out in the group’s small observational pilot study. It included 10 patients with HS who underwent surgery only after at least 6 months on adalimumab. Six had surgery for axillary HS and four for inguinal disease. Only 2 of the 10 developed a wound healing disorder. Both had surgical reconstruction in the inguinal area. Neither case involved infection. Surgical management entailed opening part of the suture to allow simultaneous secondary wound closure.
This 20% incidence of disordered wound healing when primary closure was carried out while systemic inflammation was controlled via adalimumab is markedly lower than rates reported using primary closure without adalimumab. Dr. Girbig and her coinvestigators are now conducting a larger controlled study to confirm their findings.
She reported having no financial conflicts regarding her study.
FROM THE EADV CONGRESS
Expert shares key facts about keloid therapy
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
FROM MEDSCAPELIVE LAS VEGAS DERMATOLOGY SEMINAR
Dermatologists play a key role in the transformation of transgender patients
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
, according to Doris Day, MD.
While clinical management of this patient population has historically been limited to experts in mental health, endocrinology, and select surgeons with experience in sex reassignment surgery, “what dermatologists provide on an aesthetic level through noninvasive or minimally invasive procedures can have a big impact in helping that transformation,” Dr. Day, of the department of dermatology at New York University Langone Health, said during the virtual annual Masters of Aesthetics Symposium. “But, we have to go through a transformation of sorts as well as we care for these patients, because we need to help them in the way that best matches their needs. We need to know about their mental health and the medicines they’re taking as well as their goals for their outcomes. If they’re working with surgeons for sex reassignment, we should have discussions with those clinicians as well.”
Gender-affirming hormone therapy is the primary medical intervention sought by transgender people, she said. This allows the acquisition of secondary sex characteristics more aligned with their gender identity. Feminizing hormone therapy affects the skin by reducing sebaceous gland activity, “which can lead to fewer acne breakouts and smaller pores but also cause drier skin,” Dr. Day said. “We can slow down the growth of body and facial hair and we can perform hair removal treatments. We see decreased male-pattern scalp hair loss, and we see smoother skin as the fat under the skin becomes thicker and the pores become smaller. We can also have increased pigment production, which is always a good thing.”
In a 2016 survey of 327 transgender individuals led by Dr. Day’s mentee, Brian A. Ginsberg, MD, and published in the Journal of the American Academy of Dermatology, most transgender women indicated that their face was most important to have changed, while for men it was the chest. Hair removal was the most common women’s facial procedure, followed by surgery then injectables, mostly performed by plastic surgeons.
Limitations of hormone therapy include the fact that it can take 2 or more years for associated changes to fully develop. “At least here in New York, patients want everything in a New York minute, so that’s always an issue,” she said. “We often recommend that patients wait at least 2 years after beginning hormone therapy before considering drastic feminization surgeries, but there are many options we have for them while they’re waiting for that. Even with hormone therapy, the bone structure of the face is unaffected, so we need to be artistic in creating a more feminized balance in order to help them physically match their gender to their identity.”
Noninvasive aesthetic procedures can compound the effects of hormone therapy, in addition to offering physical transformation beyond hormone therapy. She recalled assisting one of her patients transform from male to female. Over a period of 2 years, Dr. Day added Botox then Juvederm Voluma to the patient’s cheeks and chin, “and she started her transformation to a more feminized gender matching identity,” she said. Next came a hair transplant and the injection of more Voluma and fillers in the lips and cheeks on an as-needed basis.
“During one visit, I felt that we could still do more,” Dr. Day recalled. “She looked at me and said, ‘Actually, I feel so happy. This looks like me as I imagined I would look in my mind.’ I realized that my vision for her wasn’t the same as her vision for herself. She was thrilled with her transformation. I realized that as we see these patients, for all we learn about the science of gender transformation, the emotional aspects of our vision of what we can accomplish for our patients versus their vision of what their happiness level is may not entirely match. We have to be careful to help them celebrate their version of their femininity or masculinity, rather than trying to have our patients match what we think we can accomplish for them with our own sense of what femininity or masculinity is.”
Over time, Dr. Day said, the patient’s acne scars improved with fillers and microneedling treatments, and with the hormone therapy. “As we softened her appearance and as she made changes like the earrings that she wore and the hair style that she chose, she was in line with what her perception of her femininity was,” she said. “Little by little we’ve been watching her grow into her new self. It’s been a beautiful transformation. I was honored to be able to share in that journey with her.”
Dr. Day reported having no relevant financial disclosures.
FROM MOA 2020
Are laser treatments better than steroids for lichen sclerosus?
Laser treatment for lichen sclerosus was noninferior to steroid therapy after 6 months and may lead to better outcomes on various patient- and physician-reported measures, according to trial results presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Patients with lichen sclerosus often present with itching, burning, and dysuria. Untreated, the vulvar dystrophy can cause architectural changes and is associated with an increased risk of vulvar malignancies.
Topical steroids are the standard treatment. To assess whether fractional CO2 laser treatment is noninferior to clobetasol propionate at 6 months, Linda Burkett, MD, and colleagues conducted a randomized controlled trial. Dr. Burkett is affiliated with MedStar Washington Hospital Center and Georgetown University in Washington and UPMC Magee-Womens Hospital in Pittsburgh.
The researchers enrolled 52 postmenopausal women with biopsy-proven lichen sclerosus. Patients had to have significant symptoms reflected by a score of at least 21 on the Skindex-29.
Twenty-seven women were assigned to receive laser therapy, and 25 were assigned to receive steroids. One patient in the steroid arm was lost to follow-up. About half of the patients in each group had prior clobetasol propionate exposure.
Patients in the steroid arm were started on 0.05% clobetasol propionate used nightly for 4 weeks, then three times per week for 8 weeks, and then as needed. They had a phone call follow-up at 2 weeks to confirm compliance and an optional in-person appointment at 3 months.
Patients in the laser arm received three laser treatments 4-6 weeks apart.
At 6 months, all patients returned for repeat assessments. The primary outcome was the Skindex-29, a dermatologic questionnaire. Secondary outcomes included a patient visual analog scale of bothersome vulvar symptoms, a provider visual assessment score, the Vaginal Health Index, the Vulvovaginal Symptom Questionnaire, the Patient Global Impression of Improvement, and the Patient Global Impression of Satisfaction.
Average Skindex-29 scores from baseline to 6 months improved more in the laser treatment group, compared with the steroid group, for all health-related quality of life categories: overall, emotional, functional, and symptoms. “At 6 months across all scores, patients reported very little bother,” Dr. Burkett said.
Differences between the groups were statistically significant for all but the functional subscore.
Average scores on subjective secondary outcomes improved more in the laser treatment group, compared with the steroid treatment group. The between-group differences were statistically significant for irritation and the Vulvovaginal Symptom Questionnaire.
For provider-based scores, patients in the laser group had greater improvement on all measures except perianal involvement, relative to patients in the steroid group. In addition, fusion of the labia minora and phimosis worsened in the steroid group.
Differences between the groups were statistically significant for phimosis, erosion, and the Vaginal Health Index.
Significantly more patients in the laser group than in the steroid group were satisfied or very satisfied with the results at 6 months (81% vs. 41%). Patients in the laser group were more likely to report that they were better or much better (89% vs. 62%), though the difference was not statistically significant.
There were no major adverse events.
The trial – the first randomized controlled study of energy-based treatment for lichen sclerosus – was conducted at a single center, and treatment was not blinded, Dr. Burkett noted.
“The treatment effect was pretty significant in favor of laser therapy,” said Cecile A. Ferrando, MD, MPH, of the Center for Urogynecology and Pelvic Reconstructive Surgery at Cleveland Clinic, commenting on the research.
“Compliance issues with clobetasol aside,” the findings raise the question of whether laser therapy should be offered as first-line treatment, Dr. Ferrando said.
The study might have been more robust had it excluded patients with previous clobetasol propionate exposure, Dr. Ferrando added.
Dr. Burkett noted that future studies may incorporate multiple centers, histology measures, and sham laser treatments and include only women who have not previously received clobetasol propionate.
The researchers had no relevant financial disclosures. Dr. Ferrando disclosed authorship royalties from UpToDate.
SOURCE: Burkett L et al. SGS 2020, Abstract 09.
Laser treatment for lichen sclerosus was noninferior to steroid therapy after 6 months and may lead to better outcomes on various patient- and physician-reported measures, according to trial results presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Patients with lichen sclerosus often present with itching, burning, and dysuria. Untreated, the vulvar dystrophy can cause architectural changes and is associated with an increased risk of vulvar malignancies.
Topical steroids are the standard treatment. To assess whether fractional CO2 laser treatment is noninferior to clobetasol propionate at 6 months, Linda Burkett, MD, and colleagues conducted a randomized controlled trial. Dr. Burkett is affiliated with MedStar Washington Hospital Center and Georgetown University in Washington and UPMC Magee-Womens Hospital in Pittsburgh.
The researchers enrolled 52 postmenopausal women with biopsy-proven lichen sclerosus. Patients had to have significant symptoms reflected by a score of at least 21 on the Skindex-29.
Twenty-seven women were assigned to receive laser therapy, and 25 were assigned to receive steroids. One patient in the steroid arm was lost to follow-up. About half of the patients in each group had prior clobetasol propionate exposure.
Patients in the steroid arm were started on 0.05% clobetasol propionate used nightly for 4 weeks, then three times per week for 8 weeks, and then as needed. They had a phone call follow-up at 2 weeks to confirm compliance and an optional in-person appointment at 3 months.
Patients in the laser arm received three laser treatments 4-6 weeks apart.
At 6 months, all patients returned for repeat assessments. The primary outcome was the Skindex-29, a dermatologic questionnaire. Secondary outcomes included a patient visual analog scale of bothersome vulvar symptoms, a provider visual assessment score, the Vaginal Health Index, the Vulvovaginal Symptom Questionnaire, the Patient Global Impression of Improvement, and the Patient Global Impression of Satisfaction.
Average Skindex-29 scores from baseline to 6 months improved more in the laser treatment group, compared with the steroid group, for all health-related quality of life categories: overall, emotional, functional, and symptoms. “At 6 months across all scores, patients reported very little bother,” Dr. Burkett said.
Differences between the groups were statistically significant for all but the functional subscore.
Average scores on subjective secondary outcomes improved more in the laser treatment group, compared with the steroid treatment group. The between-group differences were statistically significant for irritation and the Vulvovaginal Symptom Questionnaire.
For provider-based scores, patients in the laser group had greater improvement on all measures except perianal involvement, relative to patients in the steroid group. In addition, fusion of the labia minora and phimosis worsened in the steroid group.
Differences between the groups were statistically significant for phimosis, erosion, and the Vaginal Health Index.
Significantly more patients in the laser group than in the steroid group were satisfied or very satisfied with the results at 6 months (81% vs. 41%). Patients in the laser group were more likely to report that they were better or much better (89% vs. 62%), though the difference was not statistically significant.
There were no major adverse events.
The trial – the first randomized controlled study of energy-based treatment for lichen sclerosus – was conducted at a single center, and treatment was not blinded, Dr. Burkett noted.
“The treatment effect was pretty significant in favor of laser therapy,” said Cecile A. Ferrando, MD, MPH, of the Center for Urogynecology and Pelvic Reconstructive Surgery at Cleveland Clinic, commenting on the research.
“Compliance issues with clobetasol aside,” the findings raise the question of whether laser therapy should be offered as first-line treatment, Dr. Ferrando said.
The study might have been more robust had it excluded patients with previous clobetasol propionate exposure, Dr. Ferrando added.
Dr. Burkett noted that future studies may incorporate multiple centers, histology measures, and sham laser treatments and include only women who have not previously received clobetasol propionate.
The researchers had no relevant financial disclosures. Dr. Ferrando disclosed authorship royalties from UpToDate.
SOURCE: Burkett L et al. SGS 2020, Abstract 09.
Laser treatment for lichen sclerosus was noninferior to steroid therapy after 6 months and may lead to better outcomes on various patient- and physician-reported measures, according to trial results presented at the virtual annual scientific meeting of the Society of Gynecologic Surgeons.
Patients with lichen sclerosus often present with itching, burning, and dysuria. Untreated, the vulvar dystrophy can cause architectural changes and is associated with an increased risk of vulvar malignancies.
Topical steroids are the standard treatment. To assess whether fractional CO2 laser treatment is noninferior to clobetasol propionate at 6 months, Linda Burkett, MD, and colleagues conducted a randomized controlled trial. Dr. Burkett is affiliated with MedStar Washington Hospital Center and Georgetown University in Washington and UPMC Magee-Womens Hospital in Pittsburgh.
The researchers enrolled 52 postmenopausal women with biopsy-proven lichen sclerosus. Patients had to have significant symptoms reflected by a score of at least 21 on the Skindex-29.
Twenty-seven women were assigned to receive laser therapy, and 25 were assigned to receive steroids. One patient in the steroid arm was lost to follow-up. About half of the patients in each group had prior clobetasol propionate exposure.
Patients in the steroid arm were started on 0.05% clobetasol propionate used nightly for 4 weeks, then three times per week for 8 weeks, and then as needed. They had a phone call follow-up at 2 weeks to confirm compliance and an optional in-person appointment at 3 months.
Patients in the laser arm received three laser treatments 4-6 weeks apart.
At 6 months, all patients returned for repeat assessments. The primary outcome was the Skindex-29, a dermatologic questionnaire. Secondary outcomes included a patient visual analog scale of bothersome vulvar symptoms, a provider visual assessment score, the Vaginal Health Index, the Vulvovaginal Symptom Questionnaire, the Patient Global Impression of Improvement, and the Patient Global Impression of Satisfaction.
Average Skindex-29 scores from baseline to 6 months improved more in the laser treatment group, compared with the steroid group, for all health-related quality of life categories: overall, emotional, functional, and symptoms. “At 6 months across all scores, patients reported very little bother,” Dr. Burkett said.
Differences between the groups were statistically significant for all but the functional subscore.
Average scores on subjective secondary outcomes improved more in the laser treatment group, compared with the steroid treatment group. The between-group differences were statistically significant for irritation and the Vulvovaginal Symptom Questionnaire.
For provider-based scores, patients in the laser group had greater improvement on all measures except perianal involvement, relative to patients in the steroid group. In addition, fusion of the labia minora and phimosis worsened in the steroid group.
Differences between the groups were statistically significant for phimosis, erosion, and the Vaginal Health Index.
Significantly more patients in the laser group than in the steroid group were satisfied or very satisfied with the results at 6 months (81% vs. 41%). Patients in the laser group were more likely to report that they were better or much better (89% vs. 62%), though the difference was not statistically significant.
There were no major adverse events.
The trial – the first randomized controlled study of energy-based treatment for lichen sclerosus – was conducted at a single center, and treatment was not blinded, Dr. Burkett noted.
“The treatment effect was pretty significant in favor of laser therapy,” said Cecile A. Ferrando, MD, MPH, of the Center for Urogynecology and Pelvic Reconstructive Surgery at Cleveland Clinic, commenting on the research.
“Compliance issues with clobetasol aside,” the findings raise the question of whether laser therapy should be offered as first-line treatment, Dr. Ferrando said.
The study might have been more robust had it excluded patients with previous clobetasol propionate exposure, Dr. Ferrando added.
Dr. Burkett noted that future studies may incorporate multiple centers, histology measures, and sham laser treatments and include only women who have not previously received clobetasol propionate.
The researchers had no relevant financial disclosures. Dr. Ferrando disclosed authorship royalties from UpToDate.
SOURCE: Burkett L et al. SGS 2020, Abstract 09.
FROM SGS 2020
Focus on factors that can be controlled during surgery for a good cosmetic result
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
ORLANDO – Some is to focus on those within a surgeon’s control, Robert H. Gotkin, MD, said at the ODAC Dermatology, Aesthetic, & Surgical Conference.
“Patients often judge the surgeon by the appearance of the scar. Not fair, but that’s what happens,” said Dr. Gotkin, director of plastic surgery at a private practice in Greenvale, N.Y.
What’s in a surgeon’s control? An accurate diagnosis, operating plan, knowledge of relevant anatomy, surgical technique, and tools for managing and modulating scars, he noted. Achieving a good cosmetic outcome starts before surgery with proper surgical planning, which includes a backup plan on “how to get out of trouble.” Visualize the ideal outcome of surgery in three dimensions, and know the relevant anatomy to help with surgical marking, as well as relevant muscular and vascular anatomy, and motor nerve danger zones, he advised. When performing facial reconstruction, reconstruct defects using the cosmetic units of the face, and place scars at the borders of cosmetic units, if possible, he said.
An order of priorities during surgery is also important. In the same way a vending machine that spits out ingredients to make a coffee in the wrong order will not result in a cup of coffee, he said, the surgical plan must be in an order that makes sense.
Tension is “one of the greatest enemies in surgery,” Dr. Gotkin said. Too much tension on a closure, for example, can cut off the blood supply and result in tissue ischemia, which could result in infection and dehiscence. It’s important to know one’s limitations during surgery and when in doubt, not to perform the surgery, he added. “Never do today what you can put off until tomorrow, because a lot of things heal and get better on their own,” he said.
Tools for good surgical outcome
A surgeon performing dermatologic procedures needs an operating room with good lighting, and a set of sharp surgical instruments. Use needle holders that do not lock, and handle needles with instruments instead of your fingers to hold the needles with just the right amount of tension, Dr. Gotkin said.
“There is no question” that palming a needle holder should not be done, he added. “Granted, this is a little dogmatic, but there is no use for palming a needle holder in surgery. It makes you much less accurate.”
Suture material is another important consideration. Surgeons have their pick of braided or monofilament sutures available in absorbable and nonabsorbable material. Absorbable sutures are made with synthetic materials such as polyglactin 910 (Vicryl), poliglecaprone 25 (Monocryl) and polydioxanone (PDS), while nonabsorbable sutures include those manufactured with polypropylene (Prolene). Nonabsorbable suture materials made of polyester and stainless steel exist, but are not commonly used in dermatologic surgery, he said.
The most common needles Dr. Gotkin uses in his practice are the Ethicon P-3, P-1, PS-2, and PS-6 types for precision point reverse cutting, and the PC-1 and PC-3 types for precision cosmetic procedures. Other needles that have similar shapes are marketed under different names, he noted. For local anesthesia, surgeons can use either lidocaine hydrochloride with epinephrine, 1% (1:100,000 u) for a rapid-onset, short-acting effect, or bupivacaine hydrochloride with epinephrine, 0.5% (1:200,000 u) for a slower-onset, long-acting effect. Dr. Gotkin recommends using a combination of both in a half-half mixture (1:150,000 epinephrine) with a buffer of sodium bicarbonate since both are acidic. Instead of stretching the skin before inserting the needle, he advised pinching or rubbing the skin to distract the patient from the injection instead of stretching the skin. Small gauge needles (such as 30-gauge or 27-gauge) are best for administering local anesthetic, he said.
Factor patient health into planning
When planning surgery, consider a patient’s comorbidities, previous surgeries, as well as current medications; those include anticoagulants or systemic steroids, which can affect the outcome of surgery. For patients who have had previous surgeries, determine whether they had any surgical complications, or experienced adverse outcomes such as keloids, hypertrophic scars, or soft tissue infections.
When planning your surgical “roadmap,” the general area of the surgery can factor into how a wound heals. Consider the vascularity of local tissues, and any tension in local tissues that can increase tension on the skin such as in the scalp, the foot, the ankle, or the back. Use the patient’s relaxed skin tension lines to minimize scarring. Since they were developed while experimenting on cadavers, the Langer lines of skin tension are not always ideal to use, and Kraissl’s lines, developed by a plastic surgeon, are a better guide for surgical planning, Dr. Gotkin said.
He also advised placing surgical markers on a patient in the way they’ll be lying during surgery. “I always tell people to crosshatch the fusiform design before surgery, because once you make the incision, they may open up and everything gets distorted, particularly when a patient’s lying down,” he said. “We have to put these markings on while the patient is sitting. Then, when you put your sutures in, you can use those lines to line everything up, so that you end up with a scar that fits in how you designed it when the patient was upright.” The rule is a 3:1 or 4:1 ratio for length/width when designing a fusiform incision for excision of a lesion.
Incisions are made perpendicular to the surface of the skin instead of beveled. “Repair in tension” rather than layers, Dr. Gotkin said. “It’s important when you put a needle in the skin, pronate so that the needle goes in at 90 degrees from the skin surface,” he explained. “Follow the curve of the needle through and supinate as you’re putting the needle through. That way, you get the right amount of tension and the right amount of tissue in the grasp of the needle.”
When tying sutures, Dr. Gotkin said he uses a hand tie in addition to an instrument tie, everting the skin edges as he closes subcuticular and cuticular sutures.
During surgery, gentle handling of tissues with forceps that have teeth, rather than a smooth surface, will help avoid crushing the skin. “That’s very important in plastic surgery, and it’s very important in any surgical procedure that you do,” he said.
These technical factors are “completely under the control of the surgeon,” but above all, a good surgical plan following an accurate diagnosis is most likely to yield the best result for patients, Dr. Gotkin said. “An architect wouldn’t build a house without blueprints, so you have to do the same thing when you’re doing surgery.”
Dr. Gotkin reported no relevant financial disclosures.
EXPERT ANALYSIS FROM ODAC 2020
Reassurance on general anesthesia in young kids
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
LAHAINA, HAWAII – Two recent large, well-conducted, and persuasive Jessica Sprague, MD, said at the SDEF Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.
“These two studies can be cited in conversation with parents and are very reassuring for a single episode of general anesthesia,” observed Dr. Sprague, a dermatologist at Rady Children’s Hospital and the University of California, both in San Diego.
“As a take home, I think we can feel pretty confident that single exposure to short-duration general anesthesia does not have any adverse neurocognitive effects,” she added.
In 2016, the Food and Drug Administration issued a drug safety communication that general anesthesia lasting for more than 3 hours in children aged less than 3 years, or repeated shorter-duration general anesthesia, may affect the development of children’s brains. This edict caused considerable turmoil among both physicians and parents. The warning was based upon animal studies suggesting adverse effects, including abnormal axon formation and other structural changes, impaired learning and memory, and heightened emotional reactivity to threats. Preliminary human cohort studies generated conflicting results, but were tough to interpret because of potential confounding issues, most prominently the distinct possibility that the very reason the child was undergoing general anesthesia might inherently predispose to neurodevelopmental problems, the dermatologist explained.
Enter the GAS trial, a multinational, assessor-blinded study in which 722 generally healthy infants undergoing hernia repair at 28 centers in the United States and six other countries were randomized to general anesthesia for a median of 54 minutes or awake regional anesthesia. Assessment via a detailed neuropsychological test battery and parent questionnaires at age 2 and 5 years showed no between-group differences at all. Of note, the GAS trial was funded by the FDA, the National Institutes of Health, and similar national health care agencies in the other participating countries (Lancet. 2019 Feb 16;393[10172]:664-77).
The other major recent research contribution was a province-wide Ontario study led by investigators at the Hospital for Sick Children in Toronto. This retrospective study included 2,346 sibling pairs aged 4-5 years in which one child in each pair received general anesthesia as a preschooler. All participants underwent testing using the comprehensive Early Development Instrument. Reassuringly, no between-group differences were found in any of the five domains assessed by the testing: language and cognitive development, physical health and well-being, emotional health and maturity, social knowledge and competence, and communication skills and general knowledge (JAMA Pediatr. 2019 Jan 1;173[1]:29-36).
These two studies address a pressing issue, since 10% of children in the United States and other developed countries receive general anesthesia within their first 3 years of life. Common indications in dermatology include excisional surgery, laser therapy for extensive port wine birthmarks, and diagnostic MRIs.
Dr. Sprague advised that, based upon the new data, “you definitely do not want to delay necessary imaging studies or surgeries, but MRIs can often be done without general anesthesia in infants less than 2 months old. If you have an infant who needs an MRI for something like PHACE syndrome [posterior fossa brain malformations, hemangioma, arterial lesions, cardiac abnormalities, and eye abnormalities], if you can get them in before 2 months of age sometimes you can avoid the general anesthesia if you wrap them tight enough. But once they get over 2 months ,there’s too much wiggle and it’s pretty impossible.”
Her other suggestions:
- Consider delaying nonurgent surgeries and imaging until at least age 6 months and ideally 3 years. “Parents will eventually want surgery to be done for a benign-appearing congenital nevus on the cheek, but it doesn’t necessarily need to be done before 6 months. The same with a residual hemangioma. I would recommend doing it before they go to kindergarten and before they get a sort of sense of what their self looks like, but you have some time between ages 3 and 5 to do that,” Dr. Sprague said.
- Seek out an anesthesiologist who has extensive experience with infants and young children, as is common at a dedicated children’s hospital. “If you live somewhere where the anesthesiologists are primarily seeing adult patients, they’re just not as good,” according to the pediatric dermatologist.
- Definitely consider a topical anesthesia strategy in infants who require multiple procedures, because there remains some unresolved concern about the potential neurodevelopmental impact of multiple bouts of general anesthesia.
Dr. Sprague reported having no financial conflicts regarding her presentation.
The SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Cosmeceutical ingredients to use before and after antiaging procedures
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
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), as well as 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. Write to her at [email protected].
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
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), as well as 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. Write to her at [email protected].
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
Outcomes are improved when proper skincare is practiced before and after any type of dermatologic procedure. This column reviews These are ingredients commonly used before, during, and after procedures.
I will use the first person when I am expressing my personal opinion or experience versus data reported in published studies that I reference.
Ascorbic acid
Ascorbic acid (vitamin C) is an essential cofactor necessary for lysyl hydroxylase and prolyl hydroxylase to produce collagen. Many studies have demonstrated that the use of oral and topical ascorbic acid increases collagen production by fibroblasts.1-3 Several different ascorbic acid products, varying greatly in quality, are available on the market.
Ascorbic acid is very sensitive to light and air exposure and does not penetrate well if not at a pH of 2 or 2.5. There are aqueous and lipophilic formulations. Some are produced from L-ascorbic acid, while others are made from ascorbyl palmitate, or salts such as calcium ascorbate, magnesium ascorbate, magnesium ascorbyl phosphate, sodium ascorbate, and sodium ascorbyl phosphate. Consequently, one must closely evaluate any chosen ascorbic acid preparation and pay close attention to the form used in any studies. I am discussing ascorbic acid in general, but my statements only apply to properly formulated products. Most of the studies I quote used L-ascorbic acid, which is the form studied by the late Sheldon Pinnell, MD, who was an expert on ascorbic acid.
Properly formulated L-ascorbic acid products have a low pH. Unless formulated specifically to deter stinging, these low-pH preparations will sting wounded skin. For this reason, most ascorbic acid preparations should be avoided until the skin has completely re-epithelialized. I prefer using it preprocedure and after the procedure once the skin has re-epithelialized. Alster and West showed that use of ascorbic acid – in an aqueous solution formulated not to sting – after laser resurfacing resulted in a significant decrease in post‐CO2 laser resurfacing erythema by the eighth postoperative week when compared with laser‐irradiated skin that had not received topical vitamin C.4
I prefer using ascorbic acid in patients before and after procedures involving fillers, toxins, skin tightening, and nonablative lasers. In my experience, this improves collagen production. Also, I use ascorbic acid before microneedling, but not during or after. Several case reports have cited allergic granulomatous reactions when ascorbic acid is used during microneedling procedures,5 although these reports did not involve aqueous formulations.
Defensin
Defensins are peptides that play an important role in wound repair. Defensin has exhibited the capacity to activate the leucine-rich repeat-containing G-protein–coupled receptors 5 and 6 (also known as LGR5+ and LGR6+) stem cells.6 This accelerates wound healing by stimulating LGR stem cells to form new keratinocytes that populate the epidermis.7 Using defensins prior to procedures would theoretically speed wound healing, but no studies have been published in this area. Anecdotally, it has been used after microneedling without complication. I have not used defensin in this situation, but when I have asked the audience during lectures, many practitioners have reported using it and found that it accelerates healing.
Growth factors
Growth factors are essential in the skin because they are responsible for immunomodulation, regulation of cell division, wound healing, and tissue generation.1 There are several important growth factor families, including: transforming growth factor-beta (TGF-beta), epidermal growth factor (EGF), insulin-like growth factor (IGF), platelet-derived growth factor (PDGF), and fibroblast growth factor (FGF).2 Because of the numerous different variables that play a role with growth factor function, it is difficult to know exactly which combinations are the most helpful to improve outcomes after procedures. There is some evidence to support the use of FGF, TGF-beta, and EGF, IGF, and PDGF to hasten skin healing.8,9 It is certain that growth factors play an important role in pre- and postprocedure skincare, but we do not yet know which growth factor combinations are the most effective.
Heparan sulfate
Heparan sulfate is a glycosaminoglycan found in the skin. Older cells are less responsive to growth factors than are younger cells; therefore, it is desirable to amplify the growth factor signal in older patients. Heparan sulfate has been shown to contribute to growth factors reaching the receptors on the cell surface and enhancing the cell’s ability to “hear” growth factor signals. Combining growth factors with enhancers such as heparan sulfate, defensins, ascorbic acid, and matrikines can improve outcomes of cosmetic procedures. There are not enough studies yet to substantiate which combinations are the most effective. However, I believe that if you are using a growth factor–containing product after a procedure, you should combine it with heparan sulfate to improve efficacy.
Heparan sulfate is not the same as the blood thinner heparin; however, it may affect clotting factors. It is prudent to stop heparan sulfate the day before a dermal filler procedure because of this theoretical risk. (I have not seen an increase in bruising in patients who use heparan sulfate prior to getting fillers.) I suggest using heparan sulfate–containing products with growth factors 24 hours after injecting fillers to try and enhance collagen synthesis that occurs after hyaluronic acid (HA) filler injections.10
Hyaluronic acid
Hyaluronic acid (HA) is known to increase penetration of drugs, as well as cosmeceutical ingredients.11 For this reason, it is often used before a procedure to increase efficacy of growth factors. Many practitioners report using it during microneedling to help the device glide across the skin. I have not observed or heard of any reports of adverse events from using it during microneedling.
HA has been shown to accelerate wound healing in rats12 and dental procedures.13 For this reason, it is often used after laser resurfacing and microneedling procedures and on sutured and open wounds. HA can vary in chain link and molecular weight and whether or not it is cross linked. These differences affect efficacy and should be taken into consideration when choosing an HA product. Some formulations combine various forms of HA. Because HA may increase bruising because of its effects on fibrin formation,14 I prefer not to use it 2 days prior to or the day of filler injections.15
Hydroxy acids
Pretreating skin with hydroxy acids increases dermal matrix formation,16 promotes collagen synthesis,17 and hastens stratum corneum turnover.18 Although postprocedure healing times after pretreatment with hydroxy acids has not been studied, it is very likely that pretreatment with hydroxy acids speeds healing time by increasing collagen production and cell turnover. West and Alster showed that pretreating skin with hydroxy acids prior to CO2 resurfacing did not affect the incidence of postprocedure hyperpigmentation.19
Matrikines
Matrikines are peptides that occur when extracellular matrix (ECM) macromolecules are partially degraded. These peptides interact with cell surface receptors and activate intracellular signalling pathways to modulate ECM remodeling.20 Matrikines, such as tripeptides and hexapeptides, have been shown to remove damaged collagen and elastin from the ECM.21 It is thought that these matrikines help to prepare the skin for procedures by freeing up space to allow room for newly formed collagen. Using matrikines at least 2 weeks before procedures may precondition the skin to heal faster.22
The tripeptide glycyl-histidyl-lysine (GHK) is a good example of a matrikine. When it forms a complex with copper (II) ions (GHK–Cu) it can stimulate collagen and glycosaminoglycan synthesis23 and increase tissue inhibitors of metalloproteinases, TIMP-1 and TIMP-2, which play a role in wound remodeling.24
A serum that contains tripeptide-1, hexapeptide-12, lactoferrin, and phosphatidyl serine has been shown to speed resolution of bruises and inflammation when applied after procedures. It is believed that these ingredients activate macrophages to clear hemosiderin from the skin.
Retinoids
Derived from vitamin A, the retinoid family includes compounds such as adapalene, retinol, tazarotene, trifarotene, and tretinoin. Retinoids should be used for at least 2-4 weeks prior to procedures to improve outcomes. Multiple studies have cogently revealed that pretreatment with tretinoin accelerates wound healing.25-27 Kligman assessed healing after punch biopsy in the mid-1990s and found that the wounds on arms pretreated with tretinoin cream 0.05%-0.1% were significantly diminished by 35%-37% on days 1 and 4 and 47%-50% reduced on days 6, 8, and 11 as compared with the wounds on untreated arms.28 A tretinoin pretreatment regimen of 2-4 weeks is supported by the preponderance of studies29 because peak epidermal hypertrophy emerges after 7 days of tretinoin application and normalizes after 14 days of continued treatment.30 Such an approach gives the skin time to recover from any retinoid dermatitis before the procedure is performed. Pretreatment with adapalene requires an earlier initiation period and should be introduced 5-6 weeks before procedures because it exhibits a longer half-life.31
Topical retinoids should not be used after a procedure until re-epithelialization is complete. Hung et al. applied 0.05% tretinoin cream daily for 10 days prior to partial-thickness skin wounding in a porcine model, with results revealing that re-epithelialization was accelerated with preprocedure treatment while use after the procedure slowed wound healing.32
Skin care regimen design by procedure type
Procedures can be divided into six main types: nonablative, such as peels, intense pulsed light (IPL), and vascular or pigmented lasers; microneedling or other procedures that cause open channels into the dermis; injectables such as toxins and fillers; ablative, such as CO2, erbium, and fractionated lasers; sutured wounds; and unsutured wounds. Skincare regimens that are prescribed before and after each of these procedures should take into account the Baumann Skin Type, the procedure type, whether it is pre- or postprocedure, and lifestyle issues such as sun exposure. Once the pre- and postprocedure regimen has been designed, patients should be given specific instructions as to which brands, the exact products, and the order in which to apply them.
Conclusion
To ensure the best outcomes from surgical treatments, patient education is a key step. The more that patients know and understand about the ways in which they can prepare for their procedure and treat their skin after the procedure, the better the results. Providers should give this type of information in an easy-to-follow printed instruction sheet because studies show that patients cannot remember most of the oral instructions offered by practitioners. Patients should be encouraged to ask questions during their consultation and procedure and to express any concerns with the practitioner’s office should any arise after they have returned home. These steps help improve patient compliance, satisfaction, and outcomes. Please discuss your opinions and experience with me on LinkedIn. You can also see a lecture on this topic on my website, SkinGuru.com.
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), as well as 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. Write to her at [email protected].
References
1. Murad S et al. Proc Natl Acad Sci U S A. 1981 May;78(5):2879-82.
2. Tajima S, Pinnell SR. J Dermatol Sci. 1996 Mar;11(3):250-3.
3. Geesin JC et al. J Invest Dermatol. 1988 Apr;90(4):420-4.
4. Alster TS, West TB. Dermatol Surg. 1998 Mar;24(3):331-4.
5. Soltani-Arabshahi R et al. JAMA Dermatol. 2014 Jan;150(1):68-72.
6. Lough D et al. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
7. Hirsch T et al. J Gene Med. 2009 Mar;11(3):220-8.
8. Van Brunt J, Klausner A. Nat Biotechnol. 1988 Jan 1;6:25-30.
9. Lynch SE et al. J Clin Invest. 1989 Aug;84(2):640-6.
10. Wang F et al. Arch Dermatol. 2007 Feb;143(2):155-63.
11. Huang G, Huang H. Drug Deliv. 2018 Nov;25(1):766-72.
12. Celani LM. J Surg Clin Res. 2019 Oct. doi: 10.20398/jscr.v10i2.18825.
13. Yildirim S et al. J Periodontol. 2018 Jan;89(1):36-45.
14. Weigel PH et al. Ciba Found Symp. 1989;143:248-61; discussion 261-4, 281-5.
15. Basora JF et al. Am J Case Rep. 2014 May 9;15:199-202.
16. Okano Yet al. Exp Dermatol. 2003;12 Suppl 2:57-63.
17. Bernstein EF et al. Dermatol Surg. 2001 May;27(5):429-33.
18. Hood HL et al. Food Chem Toxicol. 1999 Nov;37(11):1105-11.
19. West TB, Alster TS. Dermatol Surg. 1999 Jan;25(1):15-7.
20. Maquart FX et al. M. Biochimie. 2005 Mar-Apr;87(3-4):353-60.
21. Pickart L et al. Biomed Res Int. 2015;2015:648108.
22. Widgerow AD et al. Aesthet Surg J. 2019 Apr 8;39 (Supplement 3):S103-11.
23. Maquart FX et al. FEBS Lett. 1988 Oct 10;238(2):343-6.
24. Siméon A et al. J Invest Dermatol. 1999 Jun;112(6):957-64.
25. Vagotis FL, Brundage SR. Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
26. Stuzin JM. Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
27. Elson ML. J Am Acad Dermatol. 1998 Aug;39:S79-81.
28. Popp C et al. Br J Dermatol. 1995 Jan;132(1):46-53.
29. Orringer JS et al. J Am Acad Dermatol. 2004 Dec;51(6):940-6.
30. Kim IH et al. J Korean Med Sci. 1996 Aug;11(4):335-41.
31. Basak PY et al. Eur J Dermatol. 2002 Mar-Apr;12(2):145-8.
32. Hung VC et al. Arch Dermatol. 1989 Jan;125(1):65-9.
Lasers expunge mucosal tattoos
, researchers reported.
Mucocutaneous tattoos are relatively rare, and lasers have been used for their removal, but cases and results have not been well documented, wrote Hao Feng, MD, then of the Laser & Skin Surgery Center of New York, and the department of dermatology, New York University, and coauthors.
In a report published in Lasers in Surgery and Medicine, the clinicians noted significant improvement with no scarring or dyspigmentation at 1 month after the last treatment session in two patients, with mucosal tattoos that had not been previously treated.
In one case, a healthy 19-year-old woman with Fitzpatrick skin type II presented for removal of a 6‐month‐old, black tattoo on the mucosal surface of her lower lip. She received six treatment sessions at months 0, 1, 3, 5, 7, and 12 with a QS 694‐nm ruby laser at settings of 6-mm spot size, 20-nanosecond pulse duration, and 3.0-3.5 J/cm2.
In a second case, a 30‐year‐old man with Fitzpatrick skin type IV presented for removal of a 10‐year‐old black tattoo on his left buccal mucosa. He received one treatment with 755-nm alexandrite picosecond lasers at settings of 2.5-mm spot size, 500-picosecond pulse duration, and 3.36 J/cm2.
Both patients experienced local mild discomfort, erythema, and edema after treatment.
“Older tattoos respond better and quicker on the skin to laser treatments, and it is likely the reason why the buccal mucosa tattoo (10 years) resolved with a single treatment whereas the lower lip tattoo (6 months) required six treatments,” the authors noted.
Mucosal tattoos, they added, “tend to respond better, faster, and with less unwanted side effects than tattoos on the skin. This may relate to the fact that mucosal skin is thinner, non-keratinized, well‐vascularized, and contains less melanin content.”
As to which laser is the best choice for removing mucosal tattoos, the authors noted that it is unclear, but while they said they have been using picosecond lasers for tattoo removals, QS lasers “remain excellent treatment modalities,” they wrote.
“Given the excellent clinical response combined with lack of scarring and dyspigmentation in our highly satisfied patients, it is the authors’ opinion that laser treatment should be considered as the first‐line treatment in removing unwanted cosmetic mucosal tattoos. This can be accomplished with various wavelengths in the picosecond and nanosecond domains,” they concluded.
Dr. Feng, who is now director of laser surgery and cosmetic dermatology at the University of Connecticut Health Center, Farmington, disclosed serving as a consultant and medical monitor for Cytrellis Biosystems. Another author disclosed serving on the advisory boards for Cytrellis, Syneron Candela, and Cynosure; owning stocks or having stock options with Cytrellis; and investing in Syneron Candela, Cynosure, and Cytrellis. The remaining two authors had no disclosures.
SOURCE: Feng H et al. Lasers Surg Med. 2019 Dec 30. doi: 10.1002/lsm.23207.
, researchers reported.
Mucocutaneous tattoos are relatively rare, and lasers have been used for their removal, but cases and results have not been well documented, wrote Hao Feng, MD, then of the Laser & Skin Surgery Center of New York, and the department of dermatology, New York University, and coauthors.
In a report published in Lasers in Surgery and Medicine, the clinicians noted significant improvement with no scarring or dyspigmentation at 1 month after the last treatment session in two patients, with mucosal tattoos that had not been previously treated.
In one case, a healthy 19-year-old woman with Fitzpatrick skin type II presented for removal of a 6‐month‐old, black tattoo on the mucosal surface of her lower lip. She received six treatment sessions at months 0, 1, 3, 5, 7, and 12 with a QS 694‐nm ruby laser at settings of 6-mm spot size, 20-nanosecond pulse duration, and 3.0-3.5 J/cm2.
In a second case, a 30‐year‐old man with Fitzpatrick skin type IV presented for removal of a 10‐year‐old black tattoo on his left buccal mucosa. He received one treatment with 755-nm alexandrite picosecond lasers at settings of 2.5-mm spot size, 500-picosecond pulse duration, and 3.36 J/cm2.
Both patients experienced local mild discomfort, erythema, and edema after treatment.
“Older tattoos respond better and quicker on the skin to laser treatments, and it is likely the reason why the buccal mucosa tattoo (10 years) resolved with a single treatment whereas the lower lip tattoo (6 months) required six treatments,” the authors noted.
Mucosal tattoos, they added, “tend to respond better, faster, and with less unwanted side effects than tattoos on the skin. This may relate to the fact that mucosal skin is thinner, non-keratinized, well‐vascularized, and contains less melanin content.”
As to which laser is the best choice for removing mucosal tattoos, the authors noted that it is unclear, but while they said they have been using picosecond lasers for tattoo removals, QS lasers “remain excellent treatment modalities,” they wrote.
“Given the excellent clinical response combined with lack of scarring and dyspigmentation in our highly satisfied patients, it is the authors’ opinion that laser treatment should be considered as the first‐line treatment in removing unwanted cosmetic mucosal tattoos. This can be accomplished with various wavelengths in the picosecond and nanosecond domains,” they concluded.
Dr. Feng, who is now director of laser surgery and cosmetic dermatology at the University of Connecticut Health Center, Farmington, disclosed serving as a consultant and medical monitor for Cytrellis Biosystems. Another author disclosed serving on the advisory boards for Cytrellis, Syneron Candela, and Cynosure; owning stocks or having stock options with Cytrellis; and investing in Syneron Candela, Cynosure, and Cytrellis. The remaining two authors had no disclosures.
SOURCE: Feng H et al. Lasers Surg Med. 2019 Dec 30. doi: 10.1002/lsm.23207.
, researchers reported.
Mucocutaneous tattoos are relatively rare, and lasers have been used for their removal, but cases and results have not been well documented, wrote Hao Feng, MD, then of the Laser & Skin Surgery Center of New York, and the department of dermatology, New York University, and coauthors.
In a report published in Lasers in Surgery and Medicine, the clinicians noted significant improvement with no scarring or dyspigmentation at 1 month after the last treatment session in two patients, with mucosal tattoos that had not been previously treated.
In one case, a healthy 19-year-old woman with Fitzpatrick skin type II presented for removal of a 6‐month‐old, black tattoo on the mucosal surface of her lower lip. She received six treatment sessions at months 0, 1, 3, 5, 7, and 12 with a QS 694‐nm ruby laser at settings of 6-mm spot size, 20-nanosecond pulse duration, and 3.0-3.5 J/cm2.
In a second case, a 30‐year‐old man with Fitzpatrick skin type IV presented for removal of a 10‐year‐old black tattoo on his left buccal mucosa. He received one treatment with 755-nm alexandrite picosecond lasers at settings of 2.5-mm spot size, 500-picosecond pulse duration, and 3.36 J/cm2.
Both patients experienced local mild discomfort, erythema, and edema after treatment.
“Older tattoos respond better and quicker on the skin to laser treatments, and it is likely the reason why the buccal mucosa tattoo (10 years) resolved with a single treatment whereas the lower lip tattoo (6 months) required six treatments,” the authors noted.
Mucosal tattoos, they added, “tend to respond better, faster, and with less unwanted side effects than tattoos on the skin. This may relate to the fact that mucosal skin is thinner, non-keratinized, well‐vascularized, and contains less melanin content.”
As to which laser is the best choice for removing mucosal tattoos, the authors noted that it is unclear, but while they said they have been using picosecond lasers for tattoo removals, QS lasers “remain excellent treatment modalities,” they wrote.
“Given the excellent clinical response combined with lack of scarring and dyspigmentation in our highly satisfied patients, it is the authors’ opinion that laser treatment should be considered as the first‐line treatment in removing unwanted cosmetic mucosal tattoos. This can be accomplished with various wavelengths in the picosecond and nanosecond domains,” they concluded.
Dr. Feng, who is now director of laser surgery and cosmetic dermatology at the University of Connecticut Health Center, Farmington, disclosed serving as a consultant and medical monitor for Cytrellis Biosystems. Another author disclosed serving on the advisory boards for Cytrellis, Syneron Candela, and Cynosure; owning stocks or having stock options with Cytrellis; and investing in Syneron Candela, Cynosure, and Cytrellis. The remaining two authors had no disclosures.
SOURCE: Feng H et al. Lasers Surg Med. 2019 Dec 30. doi: 10.1002/lsm.23207.
FROM LASERS IN SURGERY AND MEDICINE
New opioid recommendations: Pain from most dermatologic procedures should be managed with acetaminophen, ibuprofen
has recommended.
Rotation flaps, interpolation flaps, wedge resections, cartilage alar-batten grafts, and Mustarde flaps were among the 20 procedures that can be managed with up to 10 oral oxycodone 5-mg equivalents, according to the panel. Only the Abbe procedure might warrant dispensing up to 15 oxycodone 5-mg pills, Justin McLawhorn, MD, and colleagues wrote in the Journal of the American Academy of Dermatology. The recommended amount of opioids are in addition to nonopioid analgesics, the guidelines point out.
All the other procedures can – and should – be managed with a combination of acetaminophen and ibuprofen, either alone or in an alternating dose pattern, said Dr. McLawhorn, of the department of dermatology at the University of Oklahoma Health Sciences Center, Oklahoma City, and coauthors.
But limited opioid prescribing is an important part of healing for patients who undergo the most invasive procedures, they wrote. “The management of complications, including adequate pain control, should be tailored to each patient on a case-by-case basis. Moreover, any pain management plan should not strictly adhere to any single guideline, but rather should be formed with consideration of the expected pain from the procedure and/or closure and consider the patient’s expectations for pain control.”
The time is ripe for dermatologists to make a stand in combating the opioid crisis, according to a group email response to questions from Dr. McLawhorn, Thomas Stasko, MD, professor and chair of dermatology at the University of Oklahoma, Oklahoma City, and Lindsey Collins, MD, also of the University of Oklahoma.
“The opioid crisis has reached epidemic proportions. More than 70,000 Americans have died from an opioid overdose in 2017,” they wrote. “Moreover, recent data suggest that nearly 6% of postsurgical, opioid-naive patients become long-term users of opioids. The lack of specific evidence-based recommendations likely contributes to a wide variety in prescribing patterns and a steady supply of unused opioids. Countering the opioid crisis necessitates a restructuring of the opioid prescribing practices that addresses pain in a procedure-specific manner. These recommendations are one tool in the dermatologists’ arsenal that can be used as a reference to help guide opioid management and prevent excessive opioid prescriptions at discharge following dermatologic interventions.”
Unfortunately, they added, dermatologists have inadvertently fueled the opioid abuse fire.
“It is difficult to quantify which providers are responsible for the onslaught of opioids into our communities,” the authors wrote in the email interview. “However, we can deduce, based on recent opioid prescribing patterns, that dermatologists provide approximately 500,000 unused opioid pills to their communities on an annual basis. This is the result of a wide variation in practice patterns and narratives that have been previously circulated in an attempt to mitigate the providers’ perception of the addictive nature of opioid analgesics. Our hope is that by addressing pain in a procedure-specific manner, we can help to limit the excessive number of unused opioid pills that are provided by dermatologists and ultimately decrease the rate of opioid-related complications, including addiction and death.”
Still, patients need and deserve effective pain management after a procedure. In the guidelines, the investigators wrote that a “one-size-fits-all” approach “does not account for the mechanism of pain, the invasiveness of the procedure, or the anatomic structures that are manipulated. As a result, current guidelines cannot accurately predict the quantity of opioids that are necessary to manage postoperative pain.”
The panel brought together experts in general dermatology, dermatologic surgery, cosmetics, and phlebology to develop a consensus on opioid prescribing guidelines for 87 of the most common procedures. Everyone on the panel was a member of the American College of Mohs Surgery, American Academy of Dermatology, or the American Vein and Lymphatic Society. The panel conducted a literature review to determine which procedures might require opioids and which would not. At least 75% of the panel had to agree on a reasonable but effective opioid amount; they were then polled as to whether they might employ that recommendation in their own clinical practice.
The recommendations are aimed at patients who experienced no peri- or postoperative complications.
The panel agreed that acetaminophen and ibuprofen – alone, in combination, or with opioids – were reasonable choices for all the 87 procedures. In such instances, acetaminophen 1 g can be staggered with ibuprofen 400 mg every 4 or 8 hours.
“I think providers will encounter a mixed bag of preconceived notions regarding patients’ expectations for pain control,” Dr. McLawhorn and coauthors wrote in the interview. “The important point for providers to make is to emphasize the noninferiority of acetaminophen and/or ibuprofen in controlling acute pain for patients who are not dependent on opioids for the management of chronic pain. Our experience in caring for many surgical patients has shown that patients are usually receptive to the use of nonopioid analgesics as many are familiar with their addictive potential because of the uptick in the publicity of the opioid-related complications.”
In cases where opioids might be appropriate, the panel unanimously agreed that dose limits be imposed. For 15 of the 87 procedures, the panel recommend a maximum prescription of 10 oxycodone 5-mg equivalents. Only one other – the Abbe flap – might warrant more, with a maximum of 15 oxycodone 5-mg pills at discharge.
Sometimes called a “lip switch,” the Abbe flap is reconstruction for full-thickness lip defects. It is a composite flap that moves skin, muscle, mucosa, and blood supply from the lower lip to reconstruct a defect of the upper lip. This reconstruction attempts to respect the native anatomic landmarks of the lip and allow for a better functional outcome.
“Because of the extensive nature of the repair and the anatomic territories that are manipulated, including the suturing of the lower lip to the upper lip with delayed separation, adequate pain control may require opioid analgesics in the immediate postoperative period,” the team wrote in the interview.
The panel could not agree on pain management strategies for five other procedures: Karapandzic flaps, en bloc nail excisions, facial resurfacing with deep chemical peels, and small- or large-volume liposuction. This was partly because of a lack of personal experience. Only 8 of the 40 panelists performed Karapandzic flaps. The maximum number of 5-mg oxycodone tablets any panelist prescribed for Karapandzic flaps and en bloc nail excisions was 20.
Facial resurfacing was likewise an uncommon procedure for the panel, with just 11 members performing this using deep chemical peels. However, five of those panelists said that opioids were routinely needed for postoperative pain with a maximum of 15 oxycodone 5-mg equivalents. And just four panelists performed liposuction, for which they used a maximum of 15 oxycodone 5-mg equivalents.
“However,” they wrote in the guidelines, “these providers noted that the location where the procedure is performed strongly influences the need for opioid pain management, with small-volume removal in the neck, arms, or flanks being unlikely to require opioids for adequate pain control, whereas large-volume removal in the thighs, knees, and hips may routinely require opioids.”
Addressing patient expectations is a very important part of pain management, the panel noted. “Patients will invariably experience postoperative pain after cutaneous surgeries or other interventions, often peaking within 4 hours after surgery. Wound tension, size and type of repair, anatomical location/nerve innervation, and patient pain tolerance are all factors that contribute to postoperative discomfort and should be considered when developing a postoperative pain management plan.”
Ultimately, according to Dr. McLawhorn and coauthors, the decision to use opioids at discharge for postoperative pain control should be an individual one based on patients’ comorbidities and expectations.
“Admittedly, many of the procedures listed within the recommendations may result in a rather large or complex defect that requires an equally large or complex repair,” they wrote in the interview. “However, proper education of the patient and provider regarding the risks of addiction with the use of opioids even short term should be discussed as part of every preoperative consultation. Furthermore, the patient and the provider must discuss their expectations for postoperative pain interventions for adequate pain control.”
SOURCE: McLawhorn J et al. J Am Acad Dermatol. 2019 Nov 12. doi: 10.1016/j.jaad.2019.09.080.
has recommended.
Rotation flaps, interpolation flaps, wedge resections, cartilage alar-batten grafts, and Mustarde flaps were among the 20 procedures that can be managed with up to 10 oral oxycodone 5-mg equivalents, according to the panel. Only the Abbe procedure might warrant dispensing up to 15 oxycodone 5-mg pills, Justin McLawhorn, MD, and colleagues wrote in the Journal of the American Academy of Dermatology. The recommended amount of opioids are in addition to nonopioid analgesics, the guidelines point out.
All the other procedures can – and should – be managed with a combination of acetaminophen and ibuprofen, either alone or in an alternating dose pattern, said Dr. McLawhorn, of the department of dermatology at the University of Oklahoma Health Sciences Center, Oklahoma City, and coauthors.
But limited opioid prescribing is an important part of healing for patients who undergo the most invasive procedures, they wrote. “The management of complications, including adequate pain control, should be tailored to each patient on a case-by-case basis. Moreover, any pain management plan should not strictly adhere to any single guideline, but rather should be formed with consideration of the expected pain from the procedure and/or closure and consider the patient’s expectations for pain control.”
The time is ripe for dermatologists to make a stand in combating the opioid crisis, according to a group email response to questions from Dr. McLawhorn, Thomas Stasko, MD, professor and chair of dermatology at the University of Oklahoma, Oklahoma City, and Lindsey Collins, MD, also of the University of Oklahoma.
“The opioid crisis has reached epidemic proportions. More than 70,000 Americans have died from an opioid overdose in 2017,” they wrote. “Moreover, recent data suggest that nearly 6% of postsurgical, opioid-naive patients become long-term users of opioids. The lack of specific evidence-based recommendations likely contributes to a wide variety in prescribing patterns and a steady supply of unused opioids. Countering the opioid crisis necessitates a restructuring of the opioid prescribing practices that addresses pain in a procedure-specific manner. These recommendations are one tool in the dermatologists’ arsenal that can be used as a reference to help guide opioid management and prevent excessive opioid prescriptions at discharge following dermatologic interventions.”
Unfortunately, they added, dermatologists have inadvertently fueled the opioid abuse fire.
“It is difficult to quantify which providers are responsible for the onslaught of opioids into our communities,” the authors wrote in the email interview. “However, we can deduce, based on recent opioid prescribing patterns, that dermatologists provide approximately 500,000 unused opioid pills to their communities on an annual basis. This is the result of a wide variation in practice patterns and narratives that have been previously circulated in an attempt to mitigate the providers’ perception of the addictive nature of opioid analgesics. Our hope is that by addressing pain in a procedure-specific manner, we can help to limit the excessive number of unused opioid pills that are provided by dermatologists and ultimately decrease the rate of opioid-related complications, including addiction and death.”
Still, patients need and deserve effective pain management after a procedure. In the guidelines, the investigators wrote that a “one-size-fits-all” approach “does not account for the mechanism of pain, the invasiveness of the procedure, or the anatomic structures that are manipulated. As a result, current guidelines cannot accurately predict the quantity of opioids that are necessary to manage postoperative pain.”
The panel brought together experts in general dermatology, dermatologic surgery, cosmetics, and phlebology to develop a consensus on opioid prescribing guidelines for 87 of the most common procedures. Everyone on the panel was a member of the American College of Mohs Surgery, American Academy of Dermatology, or the American Vein and Lymphatic Society. The panel conducted a literature review to determine which procedures might require opioids and which would not. At least 75% of the panel had to agree on a reasonable but effective opioid amount; they were then polled as to whether they might employ that recommendation in their own clinical practice.
The recommendations are aimed at patients who experienced no peri- or postoperative complications.
The panel agreed that acetaminophen and ibuprofen – alone, in combination, or with opioids – were reasonable choices for all the 87 procedures. In such instances, acetaminophen 1 g can be staggered with ibuprofen 400 mg every 4 or 8 hours.
“I think providers will encounter a mixed bag of preconceived notions regarding patients’ expectations for pain control,” Dr. McLawhorn and coauthors wrote in the interview. “The important point for providers to make is to emphasize the noninferiority of acetaminophen and/or ibuprofen in controlling acute pain for patients who are not dependent on opioids for the management of chronic pain. Our experience in caring for many surgical patients has shown that patients are usually receptive to the use of nonopioid analgesics as many are familiar with their addictive potential because of the uptick in the publicity of the opioid-related complications.”
In cases where opioids might be appropriate, the panel unanimously agreed that dose limits be imposed. For 15 of the 87 procedures, the panel recommend a maximum prescription of 10 oxycodone 5-mg equivalents. Only one other – the Abbe flap – might warrant more, with a maximum of 15 oxycodone 5-mg pills at discharge.
Sometimes called a “lip switch,” the Abbe flap is reconstruction for full-thickness lip defects. It is a composite flap that moves skin, muscle, mucosa, and blood supply from the lower lip to reconstruct a defect of the upper lip. This reconstruction attempts to respect the native anatomic landmarks of the lip and allow for a better functional outcome.
“Because of the extensive nature of the repair and the anatomic territories that are manipulated, including the suturing of the lower lip to the upper lip with delayed separation, adequate pain control may require opioid analgesics in the immediate postoperative period,” the team wrote in the interview.
The panel could not agree on pain management strategies for five other procedures: Karapandzic flaps, en bloc nail excisions, facial resurfacing with deep chemical peels, and small- or large-volume liposuction. This was partly because of a lack of personal experience. Only 8 of the 40 panelists performed Karapandzic flaps. The maximum number of 5-mg oxycodone tablets any panelist prescribed for Karapandzic flaps and en bloc nail excisions was 20.
Facial resurfacing was likewise an uncommon procedure for the panel, with just 11 members performing this using deep chemical peels. However, five of those panelists said that opioids were routinely needed for postoperative pain with a maximum of 15 oxycodone 5-mg equivalents. And just four panelists performed liposuction, for which they used a maximum of 15 oxycodone 5-mg equivalents.
“However,” they wrote in the guidelines, “these providers noted that the location where the procedure is performed strongly influences the need for opioid pain management, with small-volume removal in the neck, arms, or flanks being unlikely to require opioids for adequate pain control, whereas large-volume removal in the thighs, knees, and hips may routinely require opioids.”
Addressing patient expectations is a very important part of pain management, the panel noted. “Patients will invariably experience postoperative pain after cutaneous surgeries or other interventions, often peaking within 4 hours after surgery. Wound tension, size and type of repair, anatomical location/nerve innervation, and patient pain tolerance are all factors that contribute to postoperative discomfort and should be considered when developing a postoperative pain management plan.”
Ultimately, according to Dr. McLawhorn and coauthors, the decision to use opioids at discharge for postoperative pain control should be an individual one based on patients’ comorbidities and expectations.
“Admittedly, many of the procedures listed within the recommendations may result in a rather large or complex defect that requires an equally large or complex repair,” they wrote in the interview. “However, proper education of the patient and provider regarding the risks of addiction with the use of opioids even short term should be discussed as part of every preoperative consultation. Furthermore, the patient and the provider must discuss their expectations for postoperative pain interventions for adequate pain control.”
SOURCE: McLawhorn J et al. J Am Acad Dermatol. 2019 Nov 12. doi: 10.1016/j.jaad.2019.09.080.
has recommended.
Rotation flaps, interpolation flaps, wedge resections, cartilage alar-batten grafts, and Mustarde flaps were among the 20 procedures that can be managed with up to 10 oral oxycodone 5-mg equivalents, according to the panel. Only the Abbe procedure might warrant dispensing up to 15 oxycodone 5-mg pills, Justin McLawhorn, MD, and colleagues wrote in the Journal of the American Academy of Dermatology. The recommended amount of opioids are in addition to nonopioid analgesics, the guidelines point out.
All the other procedures can – and should – be managed with a combination of acetaminophen and ibuprofen, either alone or in an alternating dose pattern, said Dr. McLawhorn, of the department of dermatology at the University of Oklahoma Health Sciences Center, Oklahoma City, and coauthors.
But limited opioid prescribing is an important part of healing for patients who undergo the most invasive procedures, they wrote. “The management of complications, including adequate pain control, should be tailored to each patient on a case-by-case basis. Moreover, any pain management plan should not strictly adhere to any single guideline, but rather should be formed with consideration of the expected pain from the procedure and/or closure and consider the patient’s expectations for pain control.”
The time is ripe for dermatologists to make a stand in combating the opioid crisis, according to a group email response to questions from Dr. McLawhorn, Thomas Stasko, MD, professor and chair of dermatology at the University of Oklahoma, Oklahoma City, and Lindsey Collins, MD, also of the University of Oklahoma.
“The opioid crisis has reached epidemic proportions. More than 70,000 Americans have died from an opioid overdose in 2017,” they wrote. “Moreover, recent data suggest that nearly 6% of postsurgical, opioid-naive patients become long-term users of opioids. The lack of specific evidence-based recommendations likely contributes to a wide variety in prescribing patterns and a steady supply of unused opioids. Countering the opioid crisis necessitates a restructuring of the opioid prescribing practices that addresses pain in a procedure-specific manner. These recommendations are one tool in the dermatologists’ arsenal that can be used as a reference to help guide opioid management and prevent excessive opioid prescriptions at discharge following dermatologic interventions.”
Unfortunately, they added, dermatologists have inadvertently fueled the opioid abuse fire.
“It is difficult to quantify which providers are responsible for the onslaught of opioids into our communities,” the authors wrote in the email interview. “However, we can deduce, based on recent opioid prescribing patterns, that dermatologists provide approximately 500,000 unused opioid pills to their communities on an annual basis. This is the result of a wide variation in practice patterns and narratives that have been previously circulated in an attempt to mitigate the providers’ perception of the addictive nature of opioid analgesics. Our hope is that by addressing pain in a procedure-specific manner, we can help to limit the excessive number of unused opioid pills that are provided by dermatologists and ultimately decrease the rate of opioid-related complications, including addiction and death.”
Still, patients need and deserve effective pain management after a procedure. In the guidelines, the investigators wrote that a “one-size-fits-all” approach “does not account for the mechanism of pain, the invasiveness of the procedure, or the anatomic structures that are manipulated. As a result, current guidelines cannot accurately predict the quantity of opioids that are necessary to manage postoperative pain.”
The panel brought together experts in general dermatology, dermatologic surgery, cosmetics, and phlebology to develop a consensus on opioid prescribing guidelines for 87 of the most common procedures. Everyone on the panel was a member of the American College of Mohs Surgery, American Academy of Dermatology, or the American Vein and Lymphatic Society. The panel conducted a literature review to determine which procedures might require opioids and which would not. At least 75% of the panel had to agree on a reasonable but effective opioid amount; they were then polled as to whether they might employ that recommendation in their own clinical practice.
The recommendations are aimed at patients who experienced no peri- or postoperative complications.
The panel agreed that acetaminophen and ibuprofen – alone, in combination, or with opioids – were reasonable choices for all the 87 procedures. In such instances, acetaminophen 1 g can be staggered with ibuprofen 400 mg every 4 or 8 hours.
“I think providers will encounter a mixed bag of preconceived notions regarding patients’ expectations for pain control,” Dr. McLawhorn and coauthors wrote in the interview. “The important point for providers to make is to emphasize the noninferiority of acetaminophen and/or ibuprofen in controlling acute pain for patients who are not dependent on opioids for the management of chronic pain. Our experience in caring for many surgical patients has shown that patients are usually receptive to the use of nonopioid analgesics as many are familiar with their addictive potential because of the uptick in the publicity of the opioid-related complications.”
In cases where opioids might be appropriate, the panel unanimously agreed that dose limits be imposed. For 15 of the 87 procedures, the panel recommend a maximum prescription of 10 oxycodone 5-mg equivalents. Only one other – the Abbe flap – might warrant more, with a maximum of 15 oxycodone 5-mg pills at discharge.
Sometimes called a “lip switch,” the Abbe flap is reconstruction for full-thickness lip defects. It is a composite flap that moves skin, muscle, mucosa, and blood supply from the lower lip to reconstruct a defect of the upper lip. This reconstruction attempts to respect the native anatomic landmarks of the lip and allow for a better functional outcome.
“Because of the extensive nature of the repair and the anatomic territories that are manipulated, including the suturing of the lower lip to the upper lip with delayed separation, adequate pain control may require opioid analgesics in the immediate postoperative period,” the team wrote in the interview.
The panel could not agree on pain management strategies for five other procedures: Karapandzic flaps, en bloc nail excisions, facial resurfacing with deep chemical peels, and small- or large-volume liposuction. This was partly because of a lack of personal experience. Only 8 of the 40 panelists performed Karapandzic flaps. The maximum number of 5-mg oxycodone tablets any panelist prescribed for Karapandzic flaps and en bloc nail excisions was 20.
Facial resurfacing was likewise an uncommon procedure for the panel, with just 11 members performing this using deep chemical peels. However, five of those panelists said that opioids were routinely needed for postoperative pain with a maximum of 15 oxycodone 5-mg equivalents. And just four panelists performed liposuction, for which they used a maximum of 15 oxycodone 5-mg equivalents.
“However,” they wrote in the guidelines, “these providers noted that the location where the procedure is performed strongly influences the need for opioid pain management, with small-volume removal in the neck, arms, or flanks being unlikely to require opioids for adequate pain control, whereas large-volume removal in the thighs, knees, and hips may routinely require opioids.”
Addressing patient expectations is a very important part of pain management, the panel noted. “Patients will invariably experience postoperative pain after cutaneous surgeries or other interventions, often peaking within 4 hours after surgery. Wound tension, size and type of repair, anatomical location/nerve innervation, and patient pain tolerance are all factors that contribute to postoperative discomfort and should be considered when developing a postoperative pain management plan.”
Ultimately, according to Dr. McLawhorn and coauthors, the decision to use opioids at discharge for postoperative pain control should be an individual one based on patients’ comorbidities and expectations.
“Admittedly, many of the procedures listed within the recommendations may result in a rather large or complex defect that requires an equally large or complex repair,” they wrote in the interview. “However, proper education of the patient and provider regarding the risks of addiction with the use of opioids even short term should be discussed as part of every preoperative consultation. Furthermore, the patient and the provider must discuss their expectations for postoperative pain interventions for adequate pain control.”
SOURCE: McLawhorn J et al. J Am Acad Dermatol. 2019 Nov 12. doi: 10.1016/j.jaad.2019.09.080.
FROM THE JOURNAL OF THE AMERICAN ACADEMY OF DERMATOLOGY
MMS linked with better survival in early-stage melanoma
according to a retrospective cohort study.
In the study, which was published in JAMA Dermatology, patients who underwent MMS had a “modest survival advantage” when compared with those who were treated with WME, the approach recommended for treatment of invasive melanoma without nodal or extralymphatic metastases in national guidelines, reported the investigators.
“We sought herein to investigate the association of the type of surgical excision – WME or MMS – with overall survival for cases of American Joint Committee on Cancer Cancer Staging Manual 8th edition (AJCC-8) stage I invasive melanoma,” wrote Shayan Cheraghlou, of Yale University, New Haven, Conn., and colleagues.
The researchers identified a total of 70,319 patients diagnosed with stage I invasive melanoma between Jan. 1, 2004, and Dec. 31, 2014. Data were collected from the National Cancer Database, including 3,234 (4.6%) and 67,085 (95.4%) patients who underwent MMS and WME, respectively. The median age of patients in the cohort was 57 years; 47.7% were female, and almost 97% were white.
In the survival analysis, the team adjusted for clinical and tumor-specific variables and conducted a matched analysis using propensity scores. The primary outcome measured was overall survival.
After analysis, the researchers found that MMS was associated with modestly better overall survival when compared with WME after adjustments (hazard ratio, 0.86; 95% confidence interval, 0.76-0.97). In the propensity score–matched analysis, a similar modest survival advantage was seen for patients who underwent MMS (hazard ratio, 0.82; 95% CI, 0.68-0.98).
“Significant differences in treatment practices based on the treatment facility were noted, with academic facilities more than twice as likely as nonacademic facilities to use MMS,” they wrote.
The researchers acknowledged a key limitation of the study was the use of a convenience sample, as opposed to a population-based sample. As a result, the generalizability of the findings may be limited to certain treatment facilities.
“These data suggest that MMS is an effective approach compared with WME for AJCC-8 stage I invasive melanoma,” they concluded.
No funding sources were reported. The authors reported having no conflicts of interest.
SOURCE: Cheraghlou S et al. JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2890.
While controversial historically, evidence showing benefit for Mohs micrographic surgery (MMS) in patients with melanoma has been reported. The findings from the current study add to the body of retrospective data suggesting improved survival for those with early-stage disease.
The survival benefit found by Cheraghlou et al., “although relatively novel,” is not surprising. Previous population-based and database studies have demonstrated a nonsignificant trend toward a survival advantage in patients with early-stage melanoma. In addition, no survival disadvantages have been reported in any other stage of malignancy.
The primary advantage of MMS is the ability of the surgery to allow for full tumor resection. Reducing the likelihood of recurrence and ensuring local control is maximized remain key strategies to ensuring survival in patients with melanoma.
Database studies have limitations, and care should be taken not to overinterpret the results of a study with two groups of patients that are disproportionate in size. As the authors of the study note, their results support the need for prospective studies to compare surgical melanoma treatments. And until those studies can be done, “the weight of existing evidence suggests that MMS is a safe and effective treatment for melanoma.”
These comments are adapted from an accompanying editorial (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2622) by Ian Maher, MD, professor and director of dermatologic surgery at the University of Minnesota, Minneapolis. He reported having no conflicts of interest.
While controversial historically, evidence showing benefit for Mohs micrographic surgery (MMS) in patients with melanoma has been reported. The findings from the current study add to the body of retrospective data suggesting improved survival for those with early-stage disease.
The survival benefit found by Cheraghlou et al., “although relatively novel,” is not surprising. Previous population-based and database studies have demonstrated a nonsignificant trend toward a survival advantage in patients with early-stage melanoma. In addition, no survival disadvantages have been reported in any other stage of malignancy.
The primary advantage of MMS is the ability of the surgery to allow for full tumor resection. Reducing the likelihood of recurrence and ensuring local control is maximized remain key strategies to ensuring survival in patients with melanoma.
Database studies have limitations, and care should be taken not to overinterpret the results of a study with two groups of patients that are disproportionate in size. As the authors of the study note, their results support the need for prospective studies to compare surgical melanoma treatments. And until those studies can be done, “the weight of existing evidence suggests that MMS is a safe and effective treatment for melanoma.”
These comments are adapted from an accompanying editorial (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2622) by Ian Maher, MD, professor and director of dermatologic surgery at the University of Minnesota, Minneapolis. He reported having no conflicts of interest.
While controversial historically, evidence showing benefit for Mohs micrographic surgery (MMS) in patients with melanoma has been reported. The findings from the current study add to the body of retrospective data suggesting improved survival for those with early-stage disease.
The survival benefit found by Cheraghlou et al., “although relatively novel,” is not surprising. Previous population-based and database studies have demonstrated a nonsignificant trend toward a survival advantage in patients with early-stage melanoma. In addition, no survival disadvantages have been reported in any other stage of malignancy.
The primary advantage of MMS is the ability of the surgery to allow for full tumor resection. Reducing the likelihood of recurrence and ensuring local control is maximized remain key strategies to ensuring survival in patients with melanoma.
Database studies have limitations, and care should be taken not to overinterpret the results of a study with two groups of patients that are disproportionate in size. As the authors of the study note, their results support the need for prospective studies to compare surgical melanoma treatments. And until those studies can be done, “the weight of existing evidence suggests that MMS is a safe and effective treatment for melanoma.”
These comments are adapted from an accompanying editorial (JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2622) by Ian Maher, MD, professor and director of dermatologic surgery at the University of Minnesota, Minneapolis. He reported having no conflicts of interest.
according to a retrospective cohort study.
In the study, which was published in JAMA Dermatology, patients who underwent MMS had a “modest survival advantage” when compared with those who were treated with WME, the approach recommended for treatment of invasive melanoma without nodal or extralymphatic metastases in national guidelines, reported the investigators.
“We sought herein to investigate the association of the type of surgical excision – WME or MMS – with overall survival for cases of American Joint Committee on Cancer Cancer Staging Manual 8th edition (AJCC-8) stage I invasive melanoma,” wrote Shayan Cheraghlou, of Yale University, New Haven, Conn., and colleagues.
The researchers identified a total of 70,319 patients diagnosed with stage I invasive melanoma between Jan. 1, 2004, and Dec. 31, 2014. Data were collected from the National Cancer Database, including 3,234 (4.6%) and 67,085 (95.4%) patients who underwent MMS and WME, respectively. The median age of patients in the cohort was 57 years; 47.7% were female, and almost 97% were white.
In the survival analysis, the team adjusted for clinical and tumor-specific variables and conducted a matched analysis using propensity scores. The primary outcome measured was overall survival.
After analysis, the researchers found that MMS was associated with modestly better overall survival when compared with WME after adjustments (hazard ratio, 0.86; 95% confidence interval, 0.76-0.97). In the propensity score–matched analysis, a similar modest survival advantage was seen for patients who underwent MMS (hazard ratio, 0.82; 95% CI, 0.68-0.98).
“Significant differences in treatment practices based on the treatment facility were noted, with academic facilities more than twice as likely as nonacademic facilities to use MMS,” they wrote.
The researchers acknowledged a key limitation of the study was the use of a convenience sample, as opposed to a population-based sample. As a result, the generalizability of the findings may be limited to certain treatment facilities.
“These data suggest that MMS is an effective approach compared with WME for AJCC-8 stage I invasive melanoma,” they concluded.
No funding sources were reported. The authors reported having no conflicts of interest.
SOURCE: Cheraghlou S et al. JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2890.
according to a retrospective cohort study.
In the study, which was published in JAMA Dermatology, patients who underwent MMS had a “modest survival advantage” when compared with those who were treated with WME, the approach recommended for treatment of invasive melanoma without nodal or extralymphatic metastases in national guidelines, reported the investigators.
“We sought herein to investigate the association of the type of surgical excision – WME or MMS – with overall survival for cases of American Joint Committee on Cancer Cancer Staging Manual 8th edition (AJCC-8) stage I invasive melanoma,” wrote Shayan Cheraghlou, of Yale University, New Haven, Conn., and colleagues.
The researchers identified a total of 70,319 patients diagnosed with stage I invasive melanoma between Jan. 1, 2004, and Dec. 31, 2014. Data were collected from the National Cancer Database, including 3,234 (4.6%) and 67,085 (95.4%) patients who underwent MMS and WME, respectively. The median age of patients in the cohort was 57 years; 47.7% were female, and almost 97% were white.
In the survival analysis, the team adjusted for clinical and tumor-specific variables and conducted a matched analysis using propensity scores. The primary outcome measured was overall survival.
After analysis, the researchers found that MMS was associated with modestly better overall survival when compared with WME after adjustments (hazard ratio, 0.86; 95% confidence interval, 0.76-0.97). In the propensity score–matched analysis, a similar modest survival advantage was seen for patients who underwent MMS (hazard ratio, 0.82; 95% CI, 0.68-0.98).
“Significant differences in treatment practices based on the treatment facility were noted, with academic facilities more than twice as likely as nonacademic facilities to use MMS,” they wrote.
The researchers acknowledged a key limitation of the study was the use of a convenience sample, as opposed to a population-based sample. As a result, the generalizability of the findings may be limited to certain treatment facilities.
“These data suggest that MMS is an effective approach compared with WME for AJCC-8 stage I invasive melanoma,” they concluded.
No funding sources were reported. The authors reported having no conflicts of interest.
SOURCE: Cheraghlou S et al. JAMA Dermatol. 2019 Sep 25. doi: 10.1001/jamadermatol.2019.2890.
FROM JAMA DERMATOLOGY