Lily Talakoub, MD

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

II. Infraorbital edema (“puffiness”)

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

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

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

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

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

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

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

III: Periorbital hyperpigmentation (“dark circles”)

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

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

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

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

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

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

IV: Infraorbital tear trough depression

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

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

V: Periorbital vascular prominence

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

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

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

VI: Periorbital static and dynamic rhytids

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

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

Additional tips for your patients:

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

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

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

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

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

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

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

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

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

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

II. Infraorbital edema (“puffiness”)

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

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

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

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

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

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

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

III: Periorbital hyperpigmentation (“dark circles”)

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

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

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

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

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

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

IV: Infraorbital tear trough depression

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

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

V: Periorbital vascular prominence

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

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

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

VI: Periorbital static and dynamic rhytids

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

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

Additional tips for your patients:

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

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

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

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

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

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

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

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

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

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

II. Infraorbital edema (“puffiness”)

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

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

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

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

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

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

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

III: Periorbital hyperpigmentation (“dark circles”)

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

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

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

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

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

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

IV: Infraorbital tear trough depression

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

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

V: Periorbital vascular prominence

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

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

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

VI: Periorbital static and dynamic rhytids

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

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

Additional tips for your patients:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

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

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

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

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

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

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

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

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

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

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

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

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

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

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

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

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

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

In a report released March 2014 by the American Society of Aesthetic Plastic Surgery, the top five surgical procedures for men were liposuction, eyelid surgery, rhinoplasty, male breast reduction, and ear surgery. However, the rate of noninvasive cosmetic procedures and sales of men’s grooming products is one of the leading segments of the beauty industry.

Although most scientific research and media are focused on the female aesthetic, understanding the specific needs of your male patients is key to patient satisfaction. Most men are generally less aware than are women of the treatment options and risks and benefits of procedures. Men also prefer treatments with less downtime and natural-looking results. This column continues our miniseries on aesthetic dermatology for the male patient.

In a general dermatology practice, there are several skin concerns often identified by male patients, and acne and rosacea are among them.

Acne: Men generally have thicker, more sebaceous skin than that of women. Although acne is a very common problem in teens and young men, there is a growing trend of cases of cystic acne in adult men who consume popular protein meal replacement or muscle enhancing shakes that contain whey protein. Whey is a protein derived from cow’s milk. Milk and dairy products act by increasing insulin-like growth factor 1, which has been linked to acne. Although few case reports have shown a link between dietary whey supplementation and acne, in my practice, men with cystic acne who report using whey supplementation products have had almost complete resolution of their acne without medical intervention after discontinuing these products.

Rosacea: Men have a higher density of facial blood vessels than women do, and often seek treatment for telangiectasias and overall facial erythema. For papulopustular rosacea, common treatments include oral antibiotics, topical antibiotics, topical azaleic acid, and topical anti-inflammatory medications. For erythematotelangiectatic rosacea, Mirvaso (brimonidine), a topical vasoconstrictor, can be applied to the skin for 8-12 hours of marked reduction in facial erythema. Although theoretically a great option for patients suffering from erythema, the effects of topical brimonidine are transient, and the gel requires daily application with no long-term benefit. Vascular laser treatments are effective for telangiectasias for both men and women. However, men with more granulomatous or phymatous rosacea often need a combination of treatments including antibiotics, oral isotretinoin and fractional ablative lasers.

Resources:

American Society for Plastic Surgery 2012 statistics.

“Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes,” Cutis 2012;90:70-2.

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

In a report released March 2014 by the American Society of Aesthetic Plastic Surgery, the top five surgical procedures for men were liposuction, eyelid surgery, rhinoplasty, male breast reduction, and ear surgery. However, the rate of noninvasive cosmetic procedures and sales of men’s grooming products is one of the leading segments of the beauty industry.

Although most scientific research and media are focused on the female aesthetic, understanding the specific needs of your male patients is key to patient satisfaction. Most men are generally less aware than are women of the treatment options and risks and benefits of procedures. Men also prefer treatments with less downtime and natural-looking results. This column continues our miniseries on aesthetic dermatology for the male patient.

In a general dermatology practice, there are several skin concerns often identified by male patients, and acne and rosacea are among them.

Acne: Men generally have thicker, more sebaceous skin than that of women. Although acne is a very common problem in teens and young men, there is a growing trend of cases of cystic acne in adult men who consume popular protein meal replacement or muscle enhancing shakes that contain whey protein. Whey is a protein derived from cow’s milk. Milk and dairy products act by increasing insulin-like growth factor 1, which has been linked to acne. Although few case reports have shown a link between dietary whey supplementation and acne, in my practice, men with cystic acne who report using whey supplementation products have had almost complete resolution of their acne without medical intervention after discontinuing these products.

Rosacea: Men have a higher density of facial blood vessels than women do, and often seek treatment for telangiectasias and overall facial erythema. For papulopustular rosacea, common treatments include oral antibiotics, topical antibiotics, topical azaleic acid, and topical anti-inflammatory medications. For erythematotelangiectatic rosacea, Mirvaso (brimonidine), a topical vasoconstrictor, can be applied to the skin for 8-12 hours of marked reduction in facial erythema. Although theoretically a great option for patients suffering from erythema, the effects of topical brimonidine are transient, and the gel requires daily application with no long-term benefit. Vascular laser treatments are effective for telangiectasias for both men and women. However, men with more granulomatous or phymatous rosacea often need a combination of treatments including antibiotics, oral isotretinoin and fractional ablative lasers.

Resources:

American Society for Plastic Surgery 2012 statistics.

“Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes,” Cutis 2012;90:70-2.

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

In a report released March 2014 by the American Society of Aesthetic Plastic Surgery, the top five surgical procedures for men were liposuction, eyelid surgery, rhinoplasty, male breast reduction, and ear surgery. However, the rate of noninvasive cosmetic procedures and sales of men’s grooming products is one of the leading segments of the beauty industry.

Although most scientific research and media are focused on the female aesthetic, understanding the specific needs of your male patients is key to patient satisfaction. Most men are generally less aware than are women of the treatment options and risks and benefits of procedures. Men also prefer treatments with less downtime and natural-looking results. This column continues our miniseries on aesthetic dermatology for the male patient.

In a general dermatology practice, there are several skin concerns often identified by male patients, and acne and rosacea are among them.

Acne: Men generally have thicker, more sebaceous skin than that of women. Although acne is a very common problem in teens and young men, there is a growing trend of cases of cystic acne in adult men who consume popular protein meal replacement or muscle enhancing shakes that contain whey protein. Whey is a protein derived from cow’s milk. Milk and dairy products act by increasing insulin-like growth factor 1, which has been linked to acne. Although few case reports have shown a link between dietary whey supplementation and acne, in my practice, men with cystic acne who report using whey supplementation products have had almost complete resolution of their acne without medical intervention after discontinuing these products.

Rosacea: Men have a higher density of facial blood vessels than women do, and often seek treatment for telangiectasias and overall facial erythema. For papulopustular rosacea, common treatments include oral antibiotics, topical antibiotics, topical azaleic acid, and topical anti-inflammatory medications. For erythematotelangiectatic rosacea, Mirvaso (brimonidine), a topical vasoconstrictor, can be applied to the skin for 8-12 hours of marked reduction in facial erythema. Although theoretically a great option for patients suffering from erythema, the effects of topical brimonidine are transient, and the gel requires daily application with no long-term benefit. Vascular laser treatments are effective for telangiectasias for both men and women. However, men with more granulomatous or phymatous rosacea often need a combination of treatments including antibiotics, oral isotretinoin and fractional ablative lasers.

Resources:

American Society for Plastic Surgery 2012 statistics.

“Whey protein precipitating moderate to severe acne flares in 5 teenaged athletes,” Cutis 2012;90:70-2.

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

Men make up an increasing number of dermatology patients seeking cosmetic procedures. According to data from the American Society for Dermatologic Surgery and the American Society of Plastic Surgery, 9%-10% of all cosmetic procedures performed in the United States in 2013 were on men, a 104% increase since 2000. Botulinum toxin is currently the most common minimally invasive cosmetic procedure performed in men. While the overall percentage of men undergoing treatment, compared with women, is relatively small, more than 385,000 botulinum toxin treatments were performed on men last year in the United States, an increase of 310% since 2000.

Studies have shown that men often require more units of onabotulinumtoxinA than women when treating the glabella. In a 2005 study by Alstair and Jean Carruthers, 80 men were randomized to receive 20, 40, 60, or 80 units of onabotulinumtoxinA (Botox or Vistabel). The 40-, 60-, and 80-U doses were consistently more effective than the 20-U dose was in reducing glabellar lines (duration, peak response rate, and improvement from baseline). I find this to be true in my practice. Men may often require 20-60 U in the superficial corrugator and procerus muscles, compared with 20-30 units of onabotulinumtoxinA in the same muscles in women. For the frontalis muscles, I may use 5-20 U in men, compared with 5-10 U of onabotulinumtoxinA in women, but I take care not to inject too inferiorly to avoid a heavy brow or brow ptosis. The orbicularis oculi muscles often require the similar doses of between 6-15 U (most often 12 U/side) depending on degree of muscle contraction and severity of rhytids.

In addition to differences in botulinum toxin dosing between men and women, placement of toxin also may vary. Placement in the superficial corrugator, procerus, frontalis, and orbicularis oculi muscles are often the similar and patient dependent, based on a visual assessment of where their muscles move/contract. The superficial corrugator may insert more laterally in some men, and the brow is often straighter or less arched. The difference in injection site is often at the lateral brow. In women, botulinum toxin is often injected at the lateral brow at the junction where the lateral superior portion of the orbicularis oculi muscle and frontalis meet, in order to help give the brow a "lift." Men, however, often do not want raised or arched brow. Therefore, an injection is often placed about 1 cm above the lateral brow to maintain brow position and avoid overarching, or what some may regard as feminization of the male brow.

The depressor anguli oris and orbicularis oris muscles are injected less frequently in men than in women in my practice because of seemingly decreased rhytid formation in men in these locations. The platysmal muscles may be injected in men, but their average age is older compared with women who receive injections in this location.

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

Men make up an increasing number of dermatology patients seeking cosmetic procedures. According to data from the American Society for Dermatologic Surgery and the American Society of Plastic Surgery, 9%-10% of all cosmetic procedures performed in the United States in 2013 were on men, a 104% increase since 2000. Botulinum toxin is currently the most common minimally invasive cosmetic procedure performed in men. While the overall percentage of men undergoing treatment, compared with women, is relatively small, more than 385,000 botulinum toxin treatments were performed on men last year in the United States, an increase of 310% since 2000.

Studies have shown that men often require more units of onabotulinumtoxinA than women when treating the glabella. In a 2005 study by Alstair and Jean Carruthers, 80 men were randomized to receive 20, 40, 60, or 80 units of onabotulinumtoxinA (Botox or Vistabel). The 40-, 60-, and 80-U doses were consistently more effective than the 20-U dose was in reducing glabellar lines (duration, peak response rate, and improvement from baseline). I find this to be true in my practice. Men may often require 20-60 U in the superficial corrugator and procerus muscles, compared with 20-30 units of onabotulinumtoxinA in the same muscles in women. For the frontalis muscles, I may use 5-20 U in men, compared with 5-10 U of onabotulinumtoxinA in women, but I take care not to inject too inferiorly to avoid a heavy brow or brow ptosis. The orbicularis oculi muscles often require the similar doses of between 6-15 U (most often 12 U/side) depending on degree of muscle contraction and severity of rhytids.

In addition to differences in botulinum toxin dosing between men and women, placement of toxin also may vary. Placement in the superficial corrugator, procerus, frontalis, and orbicularis oculi muscles are often the similar and patient dependent, based on a visual assessment of where their muscles move/contract. The superficial corrugator may insert more laterally in some men, and the brow is often straighter or less arched. The difference in injection site is often at the lateral brow. In women, botulinum toxin is often injected at the lateral brow at the junction where the lateral superior portion of the orbicularis oculi muscle and frontalis meet, in order to help give the brow a "lift." Men, however, often do not want raised or arched brow. Therefore, an injection is often placed about 1 cm above the lateral brow to maintain brow position and avoid overarching, or what some may regard as feminization of the male brow.

The depressor anguli oris and orbicularis oris muscles are injected less frequently in men than in women in my practice because of seemingly decreased rhytid formation in men in these locations. The platysmal muscles may be injected in men, but their average age is older compared with women who receive injections in this location.

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

Men make up an increasing number of dermatology patients seeking cosmetic procedures. According to data from the American Society for Dermatologic Surgery and the American Society of Plastic Surgery, 9%-10% of all cosmetic procedures performed in the United States in 2013 were on men, a 104% increase since 2000. Botulinum toxin is currently the most common minimally invasive cosmetic procedure performed in men. While the overall percentage of men undergoing treatment, compared with women, is relatively small, more than 385,000 botulinum toxin treatments were performed on men last year in the United States, an increase of 310% since 2000.

Studies have shown that men often require more units of onabotulinumtoxinA than women when treating the glabella. In a 2005 study by Alstair and Jean Carruthers, 80 men were randomized to receive 20, 40, 60, or 80 units of onabotulinumtoxinA (Botox or Vistabel). The 40-, 60-, and 80-U doses were consistently more effective than the 20-U dose was in reducing glabellar lines (duration, peak response rate, and improvement from baseline). I find this to be true in my practice. Men may often require 20-60 U in the superficial corrugator and procerus muscles, compared with 20-30 units of onabotulinumtoxinA in the same muscles in women. For the frontalis muscles, I may use 5-20 U in men, compared with 5-10 U of onabotulinumtoxinA in women, but I take care not to inject too inferiorly to avoid a heavy brow or brow ptosis. The orbicularis oculi muscles often require the similar doses of between 6-15 U (most often 12 U/side) depending on degree of muscle contraction and severity of rhytids.

In addition to differences in botulinum toxin dosing between men and women, placement of toxin also may vary. Placement in the superficial corrugator, procerus, frontalis, and orbicularis oculi muscles are often the similar and patient dependent, based on a visual assessment of where their muscles move/contract. The superficial corrugator may insert more laterally in some men, and the brow is often straighter or less arched. The difference in injection site is often at the lateral brow. In women, botulinum toxin is often injected at the lateral brow at the junction where the lateral superior portion of the orbicularis oculi muscle and frontalis meet, in order to help give the brow a "lift." Men, however, often do not want raised or arched brow. Therefore, an injection is often placed about 1 cm above the lateral brow to maintain brow position and avoid overarching, or what some may regard as feminization of the male brow.

The depressor anguli oris and orbicularis oris muscles are injected less frequently in men than in women in my practice because of seemingly decreased rhytid formation in men in these locations. The platysmal muscles may be injected in men, but their average age is older compared with women who receive injections in this location.

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

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

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

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

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

Summer months can be dreadful for patients with atopic dermatitis. The chlorine, heat, and humidity can lead to flares. Furthermore, noncompliance with skin care regimens because of changing summer routines, travel, and the use of hotel products can exacerbate even the calmest skin disease.

Share these tips with your patients to help them keep their atopic skin under control in the summer heat, and stop flares before they start.

• Rinse the skin well after swimming. Chlorine and saltwater can dry out the skin. Showers after swimming in chlorinated pools can help retain the skin’s natural oils.

• Avoid hot tubs. Cracks and fissures in atopic skin can become infected in hot tubs with Staphylococcus and Pseudomonas. Advise your atopic patients to avoid hot tubs, even if they claim the tubs have been cleaned.

• Bring your own products. Many soaps and shower gels available in hotels and resorts are extremely drying, and may contain ingredients that could irritate atopic skin.

• Don’t switch from thick creams to thin lotions just because it is summer. Remind your patients that a thin lotion does not provide the same occlusive and humectant properties as thicker creams, although they are not as easy to apply, and can feel thick and sticky on the skin with humidity.

• In case of an active eczema flare, topical steroids should be used and sun exposure should be avoided. Topical steroids are the most effective treatment when used correctly. However, any occurrence of hypopigmentation as a result of their use becomes more evident if the skin tans around the area of treatment.

• Wear physical sunscreen. This seems obvious, but most chemical blockers – even the formulations made for babies – can burn on cracked, inflamed skin. Instead, stress to your patients that they use a physical blocker made of pure titanium dioxide or zinc oxide on inflamed skin.

• Oral steroids and sun do not mix. Oral steroids can be potent photosensitizers. If they are needed, UV exposure should be avoided.

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