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Sodium deoxycholate and triamcinolone: A good mix?
In September 2023, Goldman et al. published a communication in Dermatologic Surgery describing their use of subcutaneous sodium deoxycholate injection (SDOC), with or without triamcinolone acetonide, for reduction of submental fat..
As they note, “patients experience a variable degree of edema and discomfort following subcutaneous injection,” of SDOC, something that I and others have also observed in our practices.
In their double-blind study of 20 patients with a baseline Clinician-Reported Submental Fat Rating Scale of 2 or 3 out of 4, 5 patients were randomized to receive SDOC as recommended in the label, while 15 received SDOC plus triamcinolone. In the latter group, 2 mL of SDOC was mixed with 0.5 mL of 40 mg/mL of triamcinolone acetate, then administered in up to 50 injections in the submentum spaced 1.0 cm apart at 0.25 mL per injection. Three treatments were administered 1 month apart.
For both groups, volumes between 5 mL and 8 mL per treatment were delivered. There were no significant differences in efficacy 30, 60, and 90 days after the final injection between the two groups. However, at day 180, the group that received only SDOC had a significantly greater reduction in submental fat, which the authors wrote indicated that the addition of triamcinolone “may mildly diminish the fat reduction effects” at that time point.
Subcutaneous SDOC (deoxycholic acid) injections for reduction of submental fullness was approved by the Food and Drug Administration in 2015 for improving the appearance of moderate to severe convexity or fullness associated with submental fat in adults. (I was involved in the clinical trials.) We found that in the trial, for optimal efficacy, most patients require two to four treatments spread at least a month apart, with patients who had larger treatment areas requiring up to six treatments.
While the clinical trial treatments were spaced 4 weeks apart, post approval, we found that patients would sometimes report further efficacy even 2-3 months post injection. Since not everyone wants to go around with edema every month for 2-4 consecutive months, spacing the treatments farther apart allows patients more time to heal and coordinate the recovery appearance around their work and social schedules.
In my practice, very rarely have we seen minimal to moderate prolonged edema, particularly in younger patients, beyond 1 month post injection. Most people have the most noticeable edema — the “bull-frog” appearance — for the first 1-3 days, with some minor fullness that appears to be almost back to baseline at 1 week. In some of these patients with prolonged submental fullness, it looks fuller than it appeared pretreatment even months afterwards.
While rare, like the study authors, I have found intralesional triamcinolone to be helpful at reducing this persistent fullness should it occur. It is likely to be reducing any persistent inflammation or posttreatment fibrosis in these patients.
Unlike the study authors, I do not combine SDOC and triamcinolone injections at the time of treatment. Rather, I consider injecting triamcinolone if submental fullness is greater than at baseline or edema persists after SDOC treatment. It is rare that I’ve had to do this, as most cases self-resolve, but I have used triamcinolone 10 mg/mL, up to 1cc total, injected 6-8 weeks apart one to three times to the affected area and found it to be effective if fullness has persisted beyond 6 months. Liposuction may also be an option, if needed, if fullness/edema persists.
Overall, SDOC is an effective treatment for small pockets of subcutaneous fat. Approved for submental fullness, it is now sometimes used off-label for other parts of the body, such as bra fat, small pockets of the abdomen, and lipomas. While some inflammation after treatment is expected — and desired — to achieve an effective outcome of fat apoptosis, intralesional triamcinolone is an interesting tool to utilize should inflammation or posttreatment fullness persist.
Dr. Wesley practices dermatology in Beverly Hills, California. Write to her at [email protected]. She was an investigator in clinical trials of Kybella.
In September 2023, Goldman et al. published a communication in Dermatologic Surgery describing their use of subcutaneous sodium deoxycholate injection (SDOC), with or without triamcinolone acetonide, for reduction of submental fat..
As they note, “patients experience a variable degree of edema and discomfort following subcutaneous injection,” of SDOC, something that I and others have also observed in our practices.
In their double-blind study of 20 patients with a baseline Clinician-Reported Submental Fat Rating Scale of 2 or 3 out of 4, 5 patients were randomized to receive SDOC as recommended in the label, while 15 received SDOC plus triamcinolone. In the latter group, 2 mL of SDOC was mixed with 0.5 mL of 40 mg/mL of triamcinolone acetate, then administered in up to 50 injections in the submentum spaced 1.0 cm apart at 0.25 mL per injection. Three treatments were administered 1 month apart.
For both groups, volumes between 5 mL and 8 mL per treatment were delivered. There were no significant differences in efficacy 30, 60, and 90 days after the final injection between the two groups. However, at day 180, the group that received only SDOC had a significantly greater reduction in submental fat, which the authors wrote indicated that the addition of triamcinolone “may mildly diminish the fat reduction effects” at that time point.
Subcutaneous SDOC (deoxycholic acid) injections for reduction of submental fullness was approved by the Food and Drug Administration in 2015 for improving the appearance of moderate to severe convexity or fullness associated with submental fat in adults. (I was involved in the clinical trials.) We found that in the trial, for optimal efficacy, most patients require two to four treatments spread at least a month apart, with patients who had larger treatment areas requiring up to six treatments.
While the clinical trial treatments were spaced 4 weeks apart, post approval, we found that patients would sometimes report further efficacy even 2-3 months post injection. Since not everyone wants to go around with edema every month for 2-4 consecutive months, spacing the treatments farther apart allows patients more time to heal and coordinate the recovery appearance around their work and social schedules.
In my practice, very rarely have we seen minimal to moderate prolonged edema, particularly in younger patients, beyond 1 month post injection. Most people have the most noticeable edema — the “bull-frog” appearance — for the first 1-3 days, with some minor fullness that appears to be almost back to baseline at 1 week. In some of these patients with prolonged submental fullness, it looks fuller than it appeared pretreatment even months afterwards.
While rare, like the study authors, I have found intralesional triamcinolone to be helpful at reducing this persistent fullness should it occur. It is likely to be reducing any persistent inflammation or posttreatment fibrosis in these patients.
Unlike the study authors, I do not combine SDOC and triamcinolone injections at the time of treatment. Rather, I consider injecting triamcinolone if submental fullness is greater than at baseline or edema persists after SDOC treatment. It is rare that I’ve had to do this, as most cases self-resolve, but I have used triamcinolone 10 mg/mL, up to 1cc total, injected 6-8 weeks apart one to three times to the affected area and found it to be effective if fullness has persisted beyond 6 months. Liposuction may also be an option, if needed, if fullness/edema persists.
Overall, SDOC is an effective treatment for small pockets of subcutaneous fat. Approved for submental fullness, it is now sometimes used off-label for other parts of the body, such as bra fat, small pockets of the abdomen, and lipomas. While some inflammation after treatment is expected — and desired — to achieve an effective outcome of fat apoptosis, intralesional triamcinolone is an interesting tool to utilize should inflammation or posttreatment fullness persist.
Dr. Wesley practices dermatology in Beverly Hills, California. Write to her at [email protected]. She was an investigator in clinical trials of Kybella.
In September 2023, Goldman et al. published a communication in Dermatologic Surgery describing their use of subcutaneous sodium deoxycholate injection (SDOC), with or without triamcinolone acetonide, for reduction of submental fat..
As they note, “patients experience a variable degree of edema and discomfort following subcutaneous injection,” of SDOC, something that I and others have also observed in our practices.
In their double-blind study of 20 patients with a baseline Clinician-Reported Submental Fat Rating Scale of 2 or 3 out of 4, 5 patients were randomized to receive SDOC as recommended in the label, while 15 received SDOC plus triamcinolone. In the latter group, 2 mL of SDOC was mixed with 0.5 mL of 40 mg/mL of triamcinolone acetate, then administered in up to 50 injections in the submentum spaced 1.0 cm apart at 0.25 mL per injection. Three treatments were administered 1 month apart.
For both groups, volumes between 5 mL and 8 mL per treatment were delivered. There were no significant differences in efficacy 30, 60, and 90 days after the final injection between the two groups. However, at day 180, the group that received only SDOC had a significantly greater reduction in submental fat, which the authors wrote indicated that the addition of triamcinolone “may mildly diminish the fat reduction effects” at that time point.
Subcutaneous SDOC (deoxycholic acid) injections for reduction of submental fullness was approved by the Food and Drug Administration in 2015 for improving the appearance of moderate to severe convexity or fullness associated with submental fat in adults. (I was involved in the clinical trials.) We found that in the trial, for optimal efficacy, most patients require two to four treatments spread at least a month apart, with patients who had larger treatment areas requiring up to six treatments.
While the clinical trial treatments were spaced 4 weeks apart, post approval, we found that patients would sometimes report further efficacy even 2-3 months post injection. Since not everyone wants to go around with edema every month for 2-4 consecutive months, spacing the treatments farther apart allows patients more time to heal and coordinate the recovery appearance around their work and social schedules.
In my practice, very rarely have we seen minimal to moderate prolonged edema, particularly in younger patients, beyond 1 month post injection. Most people have the most noticeable edema — the “bull-frog” appearance — for the first 1-3 days, with some minor fullness that appears to be almost back to baseline at 1 week. In some of these patients with prolonged submental fullness, it looks fuller than it appeared pretreatment even months afterwards.
While rare, like the study authors, I have found intralesional triamcinolone to be helpful at reducing this persistent fullness should it occur. It is likely to be reducing any persistent inflammation or posttreatment fibrosis in these patients.
Unlike the study authors, I do not combine SDOC and triamcinolone injections at the time of treatment. Rather, I consider injecting triamcinolone if submental fullness is greater than at baseline or edema persists after SDOC treatment. It is rare that I’ve had to do this, as most cases self-resolve, but I have used triamcinolone 10 mg/mL, up to 1cc total, injected 6-8 weeks apart one to three times to the affected area and found it to be effective if fullness has persisted beyond 6 months. Liposuction may also be an option, if needed, if fullness/edema persists.
Overall, SDOC is an effective treatment for small pockets of subcutaneous fat. Approved for submental fullness, it is now sometimes used off-label for other parts of the body, such as bra fat, small pockets of the abdomen, and lipomas. While some inflammation after treatment is expected — and desired — to achieve an effective outcome of fat apoptosis, intralesional triamcinolone is an interesting tool to utilize should inflammation or posttreatment fullness persist.
Dr. Wesley practices dermatology in Beverly Hills, California. Write to her at [email protected]. She was an investigator in clinical trials of Kybella.
The role of social media in aesthetic trends
Recently, but I had never heard it before. Not too long afterwards, patients were asking me about it in the office, using the same terminology, and I had several calls about it in one day. When I asked one trusted patient where she’d heard this term, which seemed to be trending, she told me that she had seen it on Instagram, as an ad or a “suggested for you” post.
Whether it’s a different name or term for a cosmetic procedure or laser we use that I’ve never heard before – such as “lip flip” or trap tox (also known as “Barbie Botox”) – many of these trendy terms spread like wildfire on social media. Some of the terms may be marketing tools started and spread by doctors who perform aesthetic procedures, something I don’t recommend as it only creates confusion for patients and practitioners, similar to the confusion consumers face regarding the plethora of over-the-counter skin care options and the marketing terms used for them. Other terms and trends are also started by nonphysician or non–professionally trained providers, sometimes leading to an unsafe or misleading term for an aesthetic procedure.
Over the past few years, several articles about the impact of social media in aesthetics have been published. In one recent paper, published in 2022, Boen and Jerdan noted that 72% of people in the United States use social media, up from 5% of American adults in 2005. In the United States, they note, “YouTube is the most popular platform with 73% of adult users, followed by Facebook (69%), Instagram (37%), SnapChat (24%), and Twitter (22%). Of the sites used daily, Facebook has the most activity (74%), followed by Instagram (64%), SnapChat (63%), YouTube (51%), and Twitter (42%).” They argue that the pros of social media in aesthetic medicine include its use as an educational tool by medical professionals to educate and provide accurate information about cosmetic procedures, and that “providing factual and evidence-based medical information to the public can help to counteract the abundant misinformation that is out there.” The cons include misinformation, no credentialing verification of the provider of the information – essentially anyone can be an “influencer” – as well as the addictive nature of social media for the consumer.
Along the same lines, younger patients tend to rely more on social media in choosing treatments and providers, further perpetuating any anxiety created from misinformation and unrealistic expectations from nonmedical influencers regarding procedures, filters used on photographs, photo editing, etc., in achieving an aesthetic result.
Physicians, particularly fellowship-trained aesthetic and surgical dermatologists, plastic and reconstructive surgeons, oculoplastic surgeons, and ENT facial plastic surgeons, who have the most training, knowledge, and expertise about aesthetic procedures, often have the least amount of time to devote to education via social media, compared with nonmedical influencers. Unless sponsored, they are also not being compensated for using it as an educational tool, except for potential indirect compensation from using it as a marketing tool for themselves and their practices. In contrast, nonmedical influencers often have many followers and time to create content, and in some cases, this is their full-time job.
All in all, most authors agree that social media has been associated with an increased acceptance of cosmetic surgery and procedures. Whether it be a trend seen on social media, or viewing one’s appearance in a filtered or photoediting app, or seeing an image of how another person looks (similar to how people in magazines, films and on television, were viewed in the past), social media has piqued people’s interest in aesthetics. It remains a balance for interested physicians to help keep information about cosmetic procedures presented in a healthy, interesting, professional, and accurate manner, and in a non–time-consuming way.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
References
Boen M and Jerdan K. Clin Dermatol. 2022 Jan-Feb;40(1):45-8.
Chen J et al. JAMA Facial Plast Surg. 2019 Sep 1;21(5):361-7.
Chopan M et al. Plast Reconstr Surg. 2019 Apr;143(4):1259-65.
Recently, but I had never heard it before. Not too long afterwards, patients were asking me about it in the office, using the same terminology, and I had several calls about it in one day. When I asked one trusted patient where she’d heard this term, which seemed to be trending, she told me that she had seen it on Instagram, as an ad or a “suggested for you” post.
Whether it’s a different name or term for a cosmetic procedure or laser we use that I’ve never heard before – such as “lip flip” or trap tox (also known as “Barbie Botox”) – many of these trendy terms spread like wildfire on social media. Some of the terms may be marketing tools started and spread by doctors who perform aesthetic procedures, something I don’t recommend as it only creates confusion for patients and practitioners, similar to the confusion consumers face regarding the plethora of over-the-counter skin care options and the marketing terms used for them. Other terms and trends are also started by nonphysician or non–professionally trained providers, sometimes leading to an unsafe or misleading term for an aesthetic procedure.
Over the past few years, several articles about the impact of social media in aesthetics have been published. In one recent paper, published in 2022, Boen and Jerdan noted that 72% of people in the United States use social media, up from 5% of American adults in 2005. In the United States, they note, “YouTube is the most popular platform with 73% of adult users, followed by Facebook (69%), Instagram (37%), SnapChat (24%), and Twitter (22%). Of the sites used daily, Facebook has the most activity (74%), followed by Instagram (64%), SnapChat (63%), YouTube (51%), and Twitter (42%).” They argue that the pros of social media in aesthetic medicine include its use as an educational tool by medical professionals to educate and provide accurate information about cosmetic procedures, and that “providing factual and evidence-based medical information to the public can help to counteract the abundant misinformation that is out there.” The cons include misinformation, no credentialing verification of the provider of the information – essentially anyone can be an “influencer” – as well as the addictive nature of social media for the consumer.
Along the same lines, younger patients tend to rely more on social media in choosing treatments and providers, further perpetuating any anxiety created from misinformation and unrealistic expectations from nonmedical influencers regarding procedures, filters used on photographs, photo editing, etc., in achieving an aesthetic result.
Physicians, particularly fellowship-trained aesthetic and surgical dermatologists, plastic and reconstructive surgeons, oculoplastic surgeons, and ENT facial plastic surgeons, who have the most training, knowledge, and expertise about aesthetic procedures, often have the least amount of time to devote to education via social media, compared with nonmedical influencers. Unless sponsored, they are also not being compensated for using it as an educational tool, except for potential indirect compensation from using it as a marketing tool for themselves and their practices. In contrast, nonmedical influencers often have many followers and time to create content, and in some cases, this is their full-time job.
All in all, most authors agree that social media has been associated with an increased acceptance of cosmetic surgery and procedures. Whether it be a trend seen on social media, or viewing one’s appearance in a filtered or photoediting app, or seeing an image of how another person looks (similar to how people in magazines, films and on television, were viewed in the past), social media has piqued people’s interest in aesthetics. It remains a balance for interested physicians to help keep information about cosmetic procedures presented in a healthy, interesting, professional, and accurate manner, and in a non–time-consuming way.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
References
Boen M and Jerdan K. Clin Dermatol. 2022 Jan-Feb;40(1):45-8.
Chen J et al. JAMA Facial Plast Surg. 2019 Sep 1;21(5):361-7.
Chopan M et al. Plast Reconstr Surg. 2019 Apr;143(4):1259-65.
Recently, but I had never heard it before. Not too long afterwards, patients were asking me about it in the office, using the same terminology, and I had several calls about it in one day. When I asked one trusted patient where she’d heard this term, which seemed to be trending, she told me that she had seen it on Instagram, as an ad or a “suggested for you” post.
Whether it’s a different name or term for a cosmetic procedure or laser we use that I’ve never heard before – such as “lip flip” or trap tox (also known as “Barbie Botox”) – many of these trendy terms spread like wildfire on social media. Some of the terms may be marketing tools started and spread by doctors who perform aesthetic procedures, something I don’t recommend as it only creates confusion for patients and practitioners, similar to the confusion consumers face regarding the plethora of over-the-counter skin care options and the marketing terms used for them. Other terms and trends are also started by nonphysician or non–professionally trained providers, sometimes leading to an unsafe or misleading term for an aesthetic procedure.
Over the past few years, several articles about the impact of social media in aesthetics have been published. In one recent paper, published in 2022, Boen and Jerdan noted that 72% of people in the United States use social media, up from 5% of American adults in 2005. In the United States, they note, “YouTube is the most popular platform with 73% of adult users, followed by Facebook (69%), Instagram (37%), SnapChat (24%), and Twitter (22%). Of the sites used daily, Facebook has the most activity (74%), followed by Instagram (64%), SnapChat (63%), YouTube (51%), and Twitter (42%).” They argue that the pros of social media in aesthetic medicine include its use as an educational tool by medical professionals to educate and provide accurate information about cosmetic procedures, and that “providing factual and evidence-based medical information to the public can help to counteract the abundant misinformation that is out there.” The cons include misinformation, no credentialing verification of the provider of the information – essentially anyone can be an “influencer” – as well as the addictive nature of social media for the consumer.
Along the same lines, younger patients tend to rely more on social media in choosing treatments and providers, further perpetuating any anxiety created from misinformation and unrealistic expectations from nonmedical influencers regarding procedures, filters used on photographs, photo editing, etc., in achieving an aesthetic result.
Physicians, particularly fellowship-trained aesthetic and surgical dermatologists, plastic and reconstructive surgeons, oculoplastic surgeons, and ENT facial plastic surgeons, who have the most training, knowledge, and expertise about aesthetic procedures, often have the least amount of time to devote to education via social media, compared with nonmedical influencers. Unless sponsored, they are also not being compensated for using it as an educational tool, except for potential indirect compensation from using it as a marketing tool for themselves and their practices. In contrast, nonmedical influencers often have many followers and time to create content, and in some cases, this is their full-time job.
All in all, most authors agree that social media has been associated with an increased acceptance of cosmetic surgery and procedures. Whether it be a trend seen on social media, or viewing one’s appearance in a filtered or photoediting app, or seeing an image of how another person looks (similar to how people in magazines, films and on television, were viewed in the past), social media has piqued people’s interest in aesthetics. It remains a balance for interested physicians to help keep information about cosmetic procedures presented in a healthy, interesting, professional, and accurate manner, and in a non–time-consuming way.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
References
Boen M and Jerdan K. Clin Dermatol. 2022 Jan-Feb;40(1):45-8.
Chen J et al. JAMA Facial Plast Surg. 2019 Sep 1;21(5):361-7.
Chopan M et al. Plast Reconstr Surg. 2019 Apr;143(4):1259-65.
Cleansing balms
A skin care trend, particularly in the Korean beauty product market and now worldwide, cleansing balms are a soft, yet solid variation of an oil-based cleanser. The solid oily component is combined with a surfactant or emulsifier. The cream balm texture melts into more of an oil texture once warmed with fingertips and applied to facial skin. The oils are effective at breaking down or attracting skin care products, oil, and grime on the skin surface. Once warm water is added, the oil emulsifies, and after it is wiped or rinsed off, what’s left behind is clean, hydrated skin.
They don’t tend to compromise the moisture barrier or disrupt skin pH, thus, resulting in less dry skin and have less potential to cause irritation. These products are particularly useful during drier, colder months, or in dry climates, and for those who have dry skin or eczema.
The popularity of cleansing balms has largely been based on their ability to remove makeup, similar to an oil cleanser, without the need to necessarily “double cleanse” with a regular cleanser afterward.
Alternatives to remove makeup besides cleansing balms, oil cleansers, and regular liquid water-based cleansers include micellar water (oil in water), chemical makeup removing cloths, and nonchemical makeup removing pads used with water. Micellar water is also gentle on the skin; it requires a cotton pad, tip, or cloth to remove makeup, without the need for water or washing. Both are effective, but it may be easier to remove makeup with cleansing balms, without the need for rubbing dry skin, than with micellar water. A study published in 2020 of 20 individuals reported that waterproof sunscreen was more effectively removed with a cleansing oil than a non–oil-based cleanser, with less irritation and dryness. Both were effective at removing non-waterproof sunscreen.
Both cleansing balms and oil-based cleansers need to be kept at room temperature (not in the refrigerator), since they may separate or solidify at low temperatures.
Most cleansing balms can be applied to dry skin, massaged, and rinsed off with warm water, but they are sometimes easier to remove with a wet cloth (typically either cotton or muslin). Many are nonirritating to the eyes, which is important when used to remove eye makeup and mascara on delicate skin. While many cleansing balms are noncomedogenic, residue from balms that are too thick or not rinsed off properly can contribute to comedones or milia. If residue is present after use, then “double-cleansing” with a water-based cleanser is reasonable, but not necessary for most users.
Did the development of Ponds cold cream mark the beginning of this trend? Yes and no. The creation of the first cold cream prototype has been attributed to the Greek physician, Galen (who lived in Rome), a combination of rose water, beeswax, and olive oil in 150 CE. While Ponds also has manufactured a cleansing balm, the original cold cream is a 50% moisturizer in a cleanser. So while similar in containing an oil, water, emulsifier, and thickener, and effective, it is more of a moisturizer and less of a solid oil/balm in its consistency.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
A skin care trend, particularly in the Korean beauty product market and now worldwide, cleansing balms are a soft, yet solid variation of an oil-based cleanser. The solid oily component is combined with a surfactant or emulsifier. The cream balm texture melts into more of an oil texture once warmed with fingertips and applied to facial skin. The oils are effective at breaking down or attracting skin care products, oil, and grime on the skin surface. Once warm water is added, the oil emulsifies, and after it is wiped or rinsed off, what’s left behind is clean, hydrated skin.
They don’t tend to compromise the moisture barrier or disrupt skin pH, thus, resulting in less dry skin and have less potential to cause irritation. These products are particularly useful during drier, colder months, or in dry climates, and for those who have dry skin or eczema.
The popularity of cleansing balms has largely been based on their ability to remove makeup, similar to an oil cleanser, without the need to necessarily “double cleanse” with a regular cleanser afterward.
Alternatives to remove makeup besides cleansing balms, oil cleansers, and regular liquid water-based cleansers include micellar water (oil in water), chemical makeup removing cloths, and nonchemical makeup removing pads used with water. Micellar water is also gentle on the skin; it requires a cotton pad, tip, or cloth to remove makeup, without the need for water or washing. Both are effective, but it may be easier to remove makeup with cleansing balms, without the need for rubbing dry skin, than with micellar water. A study published in 2020 of 20 individuals reported that waterproof sunscreen was more effectively removed with a cleansing oil than a non–oil-based cleanser, with less irritation and dryness. Both were effective at removing non-waterproof sunscreen.
Both cleansing balms and oil-based cleansers need to be kept at room temperature (not in the refrigerator), since they may separate or solidify at low temperatures.
Most cleansing balms can be applied to dry skin, massaged, and rinsed off with warm water, but they are sometimes easier to remove with a wet cloth (typically either cotton or muslin). Many are nonirritating to the eyes, which is important when used to remove eye makeup and mascara on delicate skin. While many cleansing balms are noncomedogenic, residue from balms that are too thick or not rinsed off properly can contribute to comedones or milia. If residue is present after use, then “double-cleansing” with a water-based cleanser is reasonable, but not necessary for most users.
Did the development of Ponds cold cream mark the beginning of this trend? Yes and no. The creation of the first cold cream prototype has been attributed to the Greek physician, Galen (who lived in Rome), a combination of rose water, beeswax, and olive oil in 150 CE. While Ponds also has manufactured a cleansing balm, the original cold cream is a 50% moisturizer in a cleanser. So while similar in containing an oil, water, emulsifier, and thickener, and effective, it is more of a moisturizer and less of a solid oil/balm in its consistency.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
A skin care trend, particularly in the Korean beauty product market and now worldwide, cleansing balms are a soft, yet solid variation of an oil-based cleanser. The solid oily component is combined with a surfactant or emulsifier. The cream balm texture melts into more of an oil texture once warmed with fingertips and applied to facial skin. The oils are effective at breaking down or attracting skin care products, oil, and grime on the skin surface. Once warm water is added, the oil emulsifies, and after it is wiped or rinsed off, what’s left behind is clean, hydrated skin.
They don’t tend to compromise the moisture barrier or disrupt skin pH, thus, resulting in less dry skin and have less potential to cause irritation. These products are particularly useful during drier, colder months, or in dry climates, and for those who have dry skin or eczema.
The popularity of cleansing balms has largely been based on their ability to remove makeup, similar to an oil cleanser, without the need to necessarily “double cleanse” with a regular cleanser afterward.
Alternatives to remove makeup besides cleansing balms, oil cleansers, and regular liquid water-based cleansers include micellar water (oil in water), chemical makeup removing cloths, and nonchemical makeup removing pads used with water. Micellar water is also gentle on the skin; it requires a cotton pad, tip, or cloth to remove makeup, without the need for water or washing. Both are effective, but it may be easier to remove makeup with cleansing balms, without the need for rubbing dry skin, than with micellar water. A study published in 2020 of 20 individuals reported that waterproof sunscreen was more effectively removed with a cleansing oil than a non–oil-based cleanser, with less irritation and dryness. Both were effective at removing non-waterproof sunscreen.
Both cleansing balms and oil-based cleansers need to be kept at room temperature (not in the refrigerator), since they may separate or solidify at low temperatures.
Most cleansing balms can be applied to dry skin, massaged, and rinsed off with warm water, but they are sometimes easier to remove with a wet cloth (typically either cotton or muslin). Many are nonirritating to the eyes, which is important when used to remove eye makeup and mascara on delicate skin. While many cleansing balms are noncomedogenic, residue from balms that are too thick or not rinsed off properly can contribute to comedones or milia. If residue is present after use, then “double-cleansing” with a water-based cleanser is reasonable, but not necessary for most users.
Did the development of Ponds cold cream mark the beginning of this trend? Yes and no. The creation of the first cold cream prototype has been attributed to the Greek physician, Galen (who lived in Rome), a combination of rose water, beeswax, and olive oil in 150 CE. While Ponds also has manufactured a cleansing balm, the original cold cream is a 50% moisturizer in a cleanser. So while similar in containing an oil, water, emulsifier, and thickener, and effective, it is more of a moisturizer and less of a solid oil/balm in its consistency.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She had no relevant disclosures.
Facial lipoatrophy with semaglutide-related weight loss
Ozempic and Wegovy are two prescription drugs that have transformed the management of type 2 diabetes and obesity. Both are a form of semaglutide; the Food and Drug Administration approved Ozempic for treating type 2 diabetes in 2017, followed by Wegovy in 2021 for weight loss in adults with obesity or those who are overweight and have least one weight-related health condition, such as hypertension or hypercholesterolemia. Ozempic is not approved for weight loss, but it has been prescribed off label for that purpose.
An effective treatment, participants with overweight or obesity in one study experienced almost a mean 15% drop in body weight with subcutaneous semaglutide administered once a week versus about 2% with placebo after 68 weeks.
In 2022, high demand and global supply constraints gave rise to shortages of both medications. The FDA reported a Wegovy shortage in March 2022, followed by an Ozempic shortage in August. Social media attention and increased off-label prescribing, with some patients purporting to have had significant improvements with weight loss and their quality of life, including having their clothing fit better and being able to bend over and tie their shoes, increased attention on these medications to the point that off-label prescribing of both drugs for weight loss resulted in some patients with type 2 diabetes unable to receive their medication on time. In late January 2023, NBC reported that Ozempic prescriptions had “tripled from 2021 to 2022,” based on data from the prescription drug discount company SingleCare.
Semaglutide is designed to mimic a hormone that signals to the brain when a person is full and promotes the release of insulin. In turn, the medications can result in lower blood glucose levels, appetite suppression, and reduced caloric intake. Injected once weekly, the medication, a glucagonlike peptide–1 receptor agonist, specifically, activates GLP-1 receptors in the brain, increasing insulin secretion, decreasing glucagon secretion, and delaying gastric emptying (acting as an incretin mimetic).
‘Ozempic face’
Common adverse events with semaglutide can include nausea, vomiting, diarrhea, abdominal pain, constipation, and injection-site reactions. Rare, but more severe adverse events may include thyroid C-cell tumor (in animal studies), medullary thyroid cancer risk, hypersensitivity reaction, anaphylaxis, acute renal injury, chronic renal failure exacerbation, pancreatitis, and cholelithiasis.
A less severe but noticeable side effect that has gained attention is facial wasting and aging, reportedly coined “Ozempic face” by a dermatologist interviewed for an article published in January in The New York Times.
As of Feb. 9, TikTok videos from individuals describing their personal experiences, health care professionals, and others with the tag #ozempicface had 4.8 million views.
Theories as to why noticeable facial changes occur with these medications include: accelerated loss of facial pads that already tend to diminish or shift with normal aging, as well as the inability of skin elasticity to keep up with the loss of volume (fat), resulting in more prominent hanging skin and the appearance of “jowls.” Wan and colleagues have described the fat pad distribution in the face and the facial aging that occurs as a result of the loss and shifting of these fat pads over time.
In the same way that we use facial fillers to help treat and correct volume/fat loss associated with photoaging, facial fillers may be used to help restore volume where it’s been lost after weight loss. The sagging skin or loss of elasticity often associated with Ozempic-related weight loss or with rapid or noticeable weight loss in general, may or may not also require other interventions that include treatment with tissue tightening devices – such as radiofrequency energy, high-focused ultrasound energy, threads, and/or surgery – such as a face lift. The potential high cost of both off-label prescribing of these medications (especially without use of prescription health insurance) as well as treatment to correct any facial wasting has also received attention in news media and social media discussions of this topic.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She has no relevant disclosures.
*Correction 1/28/23: An earlier version of this story misstated the approval date of Wegovy. It was in 2021.
Ozempic and Wegovy are two prescription drugs that have transformed the management of type 2 diabetes and obesity. Both are a form of semaglutide; the Food and Drug Administration approved Ozempic for treating type 2 diabetes in 2017, followed by Wegovy in 2021 for weight loss in adults with obesity or those who are overweight and have least one weight-related health condition, such as hypertension or hypercholesterolemia. Ozempic is not approved for weight loss, but it has been prescribed off label for that purpose.
An effective treatment, participants with overweight or obesity in one study experienced almost a mean 15% drop in body weight with subcutaneous semaglutide administered once a week versus about 2% with placebo after 68 weeks.
In 2022, high demand and global supply constraints gave rise to shortages of both medications. The FDA reported a Wegovy shortage in March 2022, followed by an Ozempic shortage in August. Social media attention and increased off-label prescribing, with some patients purporting to have had significant improvements with weight loss and their quality of life, including having their clothing fit better and being able to bend over and tie their shoes, increased attention on these medications to the point that off-label prescribing of both drugs for weight loss resulted in some patients with type 2 diabetes unable to receive their medication on time. In late January 2023, NBC reported that Ozempic prescriptions had “tripled from 2021 to 2022,” based on data from the prescription drug discount company SingleCare.
Semaglutide is designed to mimic a hormone that signals to the brain when a person is full and promotes the release of insulin. In turn, the medications can result in lower blood glucose levels, appetite suppression, and reduced caloric intake. Injected once weekly, the medication, a glucagonlike peptide–1 receptor agonist, specifically, activates GLP-1 receptors in the brain, increasing insulin secretion, decreasing glucagon secretion, and delaying gastric emptying (acting as an incretin mimetic).
‘Ozempic face’
Common adverse events with semaglutide can include nausea, vomiting, diarrhea, abdominal pain, constipation, and injection-site reactions. Rare, but more severe adverse events may include thyroid C-cell tumor (in animal studies), medullary thyroid cancer risk, hypersensitivity reaction, anaphylaxis, acute renal injury, chronic renal failure exacerbation, pancreatitis, and cholelithiasis.
A less severe but noticeable side effect that has gained attention is facial wasting and aging, reportedly coined “Ozempic face” by a dermatologist interviewed for an article published in January in The New York Times.
As of Feb. 9, TikTok videos from individuals describing their personal experiences, health care professionals, and others with the tag #ozempicface had 4.8 million views.
Theories as to why noticeable facial changes occur with these medications include: accelerated loss of facial pads that already tend to diminish or shift with normal aging, as well as the inability of skin elasticity to keep up with the loss of volume (fat), resulting in more prominent hanging skin and the appearance of “jowls.” Wan and colleagues have described the fat pad distribution in the face and the facial aging that occurs as a result of the loss and shifting of these fat pads over time.
In the same way that we use facial fillers to help treat and correct volume/fat loss associated with photoaging, facial fillers may be used to help restore volume where it’s been lost after weight loss. The sagging skin or loss of elasticity often associated with Ozempic-related weight loss or with rapid or noticeable weight loss in general, may or may not also require other interventions that include treatment with tissue tightening devices – such as radiofrequency energy, high-focused ultrasound energy, threads, and/or surgery – such as a face lift. The potential high cost of both off-label prescribing of these medications (especially without use of prescription health insurance) as well as treatment to correct any facial wasting has also received attention in news media and social media discussions of this topic.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She has no relevant disclosures.
*Correction 1/28/23: An earlier version of this story misstated the approval date of Wegovy. It was in 2021.
Ozempic and Wegovy are two prescription drugs that have transformed the management of type 2 diabetes and obesity. Both are a form of semaglutide; the Food and Drug Administration approved Ozempic for treating type 2 diabetes in 2017, followed by Wegovy in 2021 for weight loss in adults with obesity or those who are overweight and have least one weight-related health condition, such as hypertension or hypercholesterolemia. Ozempic is not approved for weight loss, but it has been prescribed off label for that purpose.
An effective treatment, participants with overweight or obesity in one study experienced almost a mean 15% drop in body weight with subcutaneous semaglutide administered once a week versus about 2% with placebo after 68 weeks.
In 2022, high demand and global supply constraints gave rise to shortages of both medications. The FDA reported a Wegovy shortage in March 2022, followed by an Ozempic shortage in August. Social media attention and increased off-label prescribing, with some patients purporting to have had significant improvements with weight loss and their quality of life, including having their clothing fit better and being able to bend over and tie their shoes, increased attention on these medications to the point that off-label prescribing of both drugs for weight loss resulted in some patients with type 2 diabetes unable to receive their medication on time. In late January 2023, NBC reported that Ozempic prescriptions had “tripled from 2021 to 2022,” based on data from the prescription drug discount company SingleCare.
Semaglutide is designed to mimic a hormone that signals to the brain when a person is full and promotes the release of insulin. In turn, the medications can result in lower blood glucose levels, appetite suppression, and reduced caloric intake. Injected once weekly, the medication, a glucagonlike peptide–1 receptor agonist, specifically, activates GLP-1 receptors in the brain, increasing insulin secretion, decreasing glucagon secretion, and delaying gastric emptying (acting as an incretin mimetic).
‘Ozempic face’
Common adverse events with semaglutide can include nausea, vomiting, diarrhea, abdominal pain, constipation, and injection-site reactions. Rare, but more severe adverse events may include thyroid C-cell tumor (in animal studies), medullary thyroid cancer risk, hypersensitivity reaction, anaphylaxis, acute renal injury, chronic renal failure exacerbation, pancreatitis, and cholelithiasis.
A less severe but noticeable side effect that has gained attention is facial wasting and aging, reportedly coined “Ozempic face” by a dermatologist interviewed for an article published in January in The New York Times.
As of Feb. 9, TikTok videos from individuals describing their personal experiences, health care professionals, and others with the tag #ozempicface had 4.8 million views.
Theories as to why noticeable facial changes occur with these medications include: accelerated loss of facial pads that already tend to diminish or shift with normal aging, as well as the inability of skin elasticity to keep up with the loss of volume (fat), resulting in more prominent hanging skin and the appearance of “jowls.” Wan and colleagues have described the fat pad distribution in the face and the facial aging that occurs as a result of the loss and shifting of these fat pads over time.
In the same way that we use facial fillers to help treat and correct volume/fat loss associated with photoaging, facial fillers may be used to help restore volume where it’s been lost after weight loss. The sagging skin or loss of elasticity often associated with Ozempic-related weight loss or with rapid or noticeable weight loss in general, may or may not also require other interventions that include treatment with tissue tightening devices – such as radiofrequency energy, high-focused ultrasound energy, threads, and/or surgery – such as a face lift. The potential high cost of both off-label prescribing of these medications (especially without use of prescription health insurance) as well as treatment to correct any facial wasting has also received attention in news media and social media discussions of this topic.
Dr. Wesley practices dermatology in Beverly Hills, Calif. Write to her at [email protected]. She has no relevant disclosures.
*Correction 1/28/23: An earlier version of this story misstated the approval date of Wegovy. It was in 2021.
Hair supplements
in JAMA Dermatology in November 2022.
Drake and colleagues evaluated the safety and efficacy of nutritional supplements for treating hair loss. In a systematic database review from inception to Oct. 20, 2021, they evaluated and compiled the findings of all dietary and nutritional interventions for treatment of hair loss among individuals without a known baseline nutritional deficiency. Thirty articles were included, including 17 randomized clinical trials, 11 clinical trials, and 2 case series.
They found the highest-quality evidence showing the most potential benefit were for 12 of the 20 nutritional interventions in their review: Pumpkin seed oil capsules, omega-3 and -6 combined with antioxidants, tocotrienol, Pantogar, capsaicin and isoflavone, Viviscal (multiple formulations), Nourkrin, Nutrafol, apple nutraceutical, Lambdapil, total glucosides of paeony and compound glycyrrhizin tablets, and zinc. Vitamin D3, kimchi and cheonggukjang, and Forti5 had lower-quality evidence for disease course improvement. Adverse effects associated with the supplements were described as mild and rare.
In practice, for patients with nonscarring alopecia, I typically check screening labs for hair loss, in addition to the clinical exam, before starting treatment (including supplements), as addressing the underlying reason, if found, is always paramount. These labs are best performed when the patient is not taking biotin, as biotin has been shown numerous times to potentially be associated with endocrine lab abnormalities, most commonly thyroid-stimulating hormone, especially at higher doses, as well as troponin levels. Some over-the-counter hair supplements will contain much higher doses than the recommended 30 micrograms per day.
Separately, if ferritin levels are within normal range, but below 50 mcg/L, supplementation with Slow Fe or another slow-release iron supplement may also result in improved hair growth. Ferritin levels are typically rechecked 6 months after supplementation to see if levels of 50 mcg/L or above have been achieved.
Another point to consider before beginning supplementation is to educate patients about potential effects of supplementation, including increased hair growth in other areas besides the scalp. For some patients who are self-conscious about potential hirsutism, this could be an issue, whereas for others, this risk does not outweigh the benefit. Unwanted hair growth, should it occur, may also be addressed with hair removal methods including shaving, waxing, plucking, threading, depilatories, prescription eflornithine cream (Vaniqa), or laser hair removal if desired.
Our armamentarium for treating hair loss includes: addressing underlying systemic causes; topical treatments including topical minoxidil; oral supplements; platelet-rich plasma injections; prescription oral medications including finasteride in men or postmenopausal women or off-label oral minoxidil; and hair transplant surgery if warranted. Having this thorough review of the most common hair supplements currently available is extremely helpful and valuable in our specialty.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. This month’s column is by Dr. Wesley. She had no relevant disclosures.
in JAMA Dermatology in November 2022.
Drake and colleagues evaluated the safety and efficacy of nutritional supplements for treating hair loss. In a systematic database review from inception to Oct. 20, 2021, they evaluated and compiled the findings of all dietary and nutritional interventions for treatment of hair loss among individuals without a known baseline nutritional deficiency. Thirty articles were included, including 17 randomized clinical trials, 11 clinical trials, and 2 case series.
They found the highest-quality evidence showing the most potential benefit were for 12 of the 20 nutritional interventions in their review: Pumpkin seed oil capsules, omega-3 and -6 combined with antioxidants, tocotrienol, Pantogar, capsaicin and isoflavone, Viviscal (multiple formulations), Nourkrin, Nutrafol, apple nutraceutical, Lambdapil, total glucosides of paeony and compound glycyrrhizin tablets, and zinc. Vitamin D3, kimchi and cheonggukjang, and Forti5 had lower-quality evidence for disease course improvement. Adverse effects associated with the supplements were described as mild and rare.
In practice, for patients with nonscarring alopecia, I typically check screening labs for hair loss, in addition to the clinical exam, before starting treatment (including supplements), as addressing the underlying reason, if found, is always paramount. These labs are best performed when the patient is not taking biotin, as biotin has been shown numerous times to potentially be associated with endocrine lab abnormalities, most commonly thyroid-stimulating hormone, especially at higher doses, as well as troponin levels. Some over-the-counter hair supplements will contain much higher doses than the recommended 30 micrograms per day.
Separately, if ferritin levels are within normal range, but below 50 mcg/L, supplementation with Slow Fe or another slow-release iron supplement may also result in improved hair growth. Ferritin levels are typically rechecked 6 months after supplementation to see if levels of 50 mcg/L or above have been achieved.
Another point to consider before beginning supplementation is to educate patients about potential effects of supplementation, including increased hair growth in other areas besides the scalp. For some patients who are self-conscious about potential hirsutism, this could be an issue, whereas for others, this risk does not outweigh the benefit. Unwanted hair growth, should it occur, may also be addressed with hair removal methods including shaving, waxing, plucking, threading, depilatories, prescription eflornithine cream (Vaniqa), or laser hair removal if desired.
Our armamentarium for treating hair loss includes: addressing underlying systemic causes; topical treatments including topical minoxidil; oral supplements; platelet-rich plasma injections; prescription oral medications including finasteride in men or postmenopausal women or off-label oral minoxidil; and hair transplant surgery if warranted. Having this thorough review of the most common hair supplements currently available is extremely helpful and valuable in our specialty.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. This month’s column is by Dr. Wesley. She had no relevant disclosures.
in JAMA Dermatology in November 2022.
Drake and colleagues evaluated the safety and efficacy of nutritional supplements for treating hair loss. In a systematic database review from inception to Oct. 20, 2021, they evaluated and compiled the findings of all dietary and nutritional interventions for treatment of hair loss among individuals without a known baseline nutritional deficiency. Thirty articles were included, including 17 randomized clinical trials, 11 clinical trials, and 2 case series.
They found the highest-quality evidence showing the most potential benefit were for 12 of the 20 nutritional interventions in their review: Pumpkin seed oil capsules, omega-3 and -6 combined with antioxidants, tocotrienol, Pantogar, capsaicin and isoflavone, Viviscal (multiple formulations), Nourkrin, Nutrafol, apple nutraceutical, Lambdapil, total glucosides of paeony and compound glycyrrhizin tablets, and zinc. Vitamin D3, kimchi and cheonggukjang, and Forti5 had lower-quality evidence for disease course improvement. Adverse effects associated with the supplements were described as mild and rare.
In practice, for patients with nonscarring alopecia, I typically check screening labs for hair loss, in addition to the clinical exam, before starting treatment (including supplements), as addressing the underlying reason, if found, is always paramount. These labs are best performed when the patient is not taking biotin, as biotin has been shown numerous times to potentially be associated with endocrine lab abnormalities, most commonly thyroid-stimulating hormone, especially at higher doses, as well as troponin levels. Some over-the-counter hair supplements will contain much higher doses than the recommended 30 micrograms per day.
Separately, if ferritin levels are within normal range, but below 50 mcg/L, supplementation with Slow Fe or another slow-release iron supplement may also result in improved hair growth. Ferritin levels are typically rechecked 6 months after supplementation to see if levels of 50 mcg/L or above have been achieved.
Another point to consider before beginning supplementation is to educate patients about potential effects of supplementation, including increased hair growth in other areas besides the scalp. For some patients who are self-conscious about potential hirsutism, this could be an issue, whereas for others, this risk does not outweigh the benefit. Unwanted hair growth, should it occur, may also be addressed with hair removal methods including shaving, waxing, plucking, threading, depilatories, prescription eflornithine cream (Vaniqa), or laser hair removal if desired.
Our armamentarium for treating hair loss includes: addressing underlying systemic causes; topical treatments including topical minoxidil; oral supplements; platelet-rich plasma injections; prescription oral medications including finasteride in men or postmenopausal women or off-label oral minoxidil; and hair transplant surgery if warranted. Having this thorough review of the most common hair supplements currently available is extremely helpful and valuable in our specialty.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. This month’s column is by Dr. Wesley. She had no relevant disclosures.
Vision loss may be a risk with PRP facial injections
A systematic review was recently conducted by Wu and colleagues examining the risk of blindness associated with platelet-rich plasma (PRP) injection. In dermatology, PRP is used more commonly now than 5 years ago to promote hair growth with injections on the scalp, as an adjunct to microneedling procedures, and sometimes – in a similar way to facial fillers – to improve volume loss, and skin tone and texture (particularly to the tear trough region).
Total unilateral blindness occurred in all cases. In one of the seven reported cases, the patient experienced recovery of vision after 3 months, but with some residual deficits noted on the ophthalmologist examination. In this case, the patient was evaluated and treated by an ophthalmologist within 3 hours of symptom onset.
In addition, four cases were reported from Venezuela, one from the United States, one from the United Kingdom, and one from Malaysia. Similar to reports of blindness with facial fillers, the most common injection site reported with this adverse effect was the glabella (five cases);
Other reports involved injections of the forehead (two), followed by the nasolabial fold (one), lateral canthus (one), and temporomandibular joint (one). Two of the seven patients received injections at more than one site, resulting in the total number of injections reported (10) being higher than the number of patients.
The risk of blindness is inherent with deep injection into a vessel that anastomoses with the blood supply to the eye. No mention was made as to whether PRP or platelet-rich fibrin was used. Other details are lacking from the original articles as to injection technique and whether or not cannula injection was used. No treatment was attempted in four of seven cases.
As plasma is native to the arteries and dissolves in the blood stream naturally, the mechanism as to why retinal artery occlusion or blindness would occur is not completely clear. One theory is that it is volume related and results from the speed of injection, causing a large rapid bolus that temporarily occludes or compresses an involved vessel.
Another theory is that damage to the vessel results from the injection itself or injection technique, leading to a clotting cascade and clot of the involved vessel with subsequent retrograde flow or blockade of the retinal artery. But if this were the case, we would expect to hear about more cases of clots leading to vascular occlusion or skin necrosis, which does not typically occur or we do not hear about.
Details about proper collection materials and technique or mixing with some other materials are also unknown in these cases, thus leaving the possibility that a more occlusive material may have been injected, as opposed to the fluid-like composition of the typical PRP preparation.With regards to risk with scalp PRP injection, the frontal scalp does receive blood supply from the supratrochlear artery that anastomoses with the angular artery of the face – both of which anastomose with the retinal artery (where occlusion would occur via back flow). The scalp tributaries are small and far enough away from the retina at that point that risk of back flow the to retinal artery should be minimal. Additionally, no reports of vascular occlusion from PRP scalp injection leading to skin necrosis have ever been reported. Of note, this is also not a risk that has been reported with the use of PRP with microneedling procedures, where PRP is placed on top of the skin before, during and after microneedling.
Anything that occludes the blood supply to the eye, whether it be fat, filler, or PRP, has an inherent risk of blindness. As there is no reversal agent or designated treatment for PRP occlusion, care must be taken to minimize risk, including awareness of anatomy and avoidance of injection into high risk areas, and cannula use where appropriate. Gentle, slow, low-volume administration, and when possible, use of a retrograde injection technique, may also be helpful.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
A systematic review was recently conducted by Wu and colleagues examining the risk of blindness associated with platelet-rich plasma (PRP) injection. In dermatology, PRP is used more commonly now than 5 years ago to promote hair growth with injections on the scalp, as an adjunct to microneedling procedures, and sometimes – in a similar way to facial fillers – to improve volume loss, and skin tone and texture (particularly to the tear trough region).
Total unilateral blindness occurred in all cases. In one of the seven reported cases, the patient experienced recovery of vision after 3 months, but with some residual deficits noted on the ophthalmologist examination. In this case, the patient was evaluated and treated by an ophthalmologist within 3 hours of symptom onset.
In addition, four cases were reported from Venezuela, one from the United States, one from the United Kingdom, and one from Malaysia. Similar to reports of blindness with facial fillers, the most common injection site reported with this adverse effect was the glabella (five cases);
Other reports involved injections of the forehead (two), followed by the nasolabial fold (one), lateral canthus (one), and temporomandibular joint (one). Two of the seven patients received injections at more than one site, resulting in the total number of injections reported (10) being higher than the number of patients.
The risk of blindness is inherent with deep injection into a vessel that anastomoses with the blood supply to the eye. No mention was made as to whether PRP or platelet-rich fibrin was used. Other details are lacking from the original articles as to injection technique and whether or not cannula injection was used. No treatment was attempted in four of seven cases.
As plasma is native to the arteries and dissolves in the blood stream naturally, the mechanism as to why retinal artery occlusion or blindness would occur is not completely clear. One theory is that it is volume related and results from the speed of injection, causing a large rapid bolus that temporarily occludes or compresses an involved vessel.
Another theory is that damage to the vessel results from the injection itself or injection technique, leading to a clotting cascade and clot of the involved vessel with subsequent retrograde flow or blockade of the retinal artery. But if this were the case, we would expect to hear about more cases of clots leading to vascular occlusion or skin necrosis, which does not typically occur or we do not hear about.
Details about proper collection materials and technique or mixing with some other materials are also unknown in these cases, thus leaving the possibility that a more occlusive material may have been injected, as opposed to the fluid-like composition of the typical PRP preparation.With regards to risk with scalp PRP injection, the frontal scalp does receive blood supply from the supratrochlear artery that anastomoses with the angular artery of the face – both of which anastomose with the retinal artery (where occlusion would occur via back flow). The scalp tributaries are small and far enough away from the retina at that point that risk of back flow the to retinal artery should be minimal. Additionally, no reports of vascular occlusion from PRP scalp injection leading to skin necrosis have ever been reported. Of note, this is also not a risk that has been reported with the use of PRP with microneedling procedures, where PRP is placed on top of the skin before, during and after microneedling.
Anything that occludes the blood supply to the eye, whether it be fat, filler, or PRP, has an inherent risk of blindness. As there is no reversal agent or designated treatment for PRP occlusion, care must be taken to minimize risk, including awareness of anatomy and avoidance of injection into high risk areas, and cannula use where appropriate. Gentle, slow, low-volume administration, and when possible, use of a retrograde injection technique, may also be helpful.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
A systematic review was recently conducted by Wu and colleagues examining the risk of blindness associated with platelet-rich plasma (PRP) injection. In dermatology, PRP is used more commonly now than 5 years ago to promote hair growth with injections on the scalp, as an adjunct to microneedling procedures, and sometimes – in a similar way to facial fillers – to improve volume loss, and skin tone and texture (particularly to the tear trough region).
Total unilateral blindness occurred in all cases. In one of the seven reported cases, the patient experienced recovery of vision after 3 months, but with some residual deficits noted on the ophthalmologist examination. In this case, the patient was evaluated and treated by an ophthalmologist within 3 hours of symptom onset.
In addition, four cases were reported from Venezuela, one from the United States, one from the United Kingdom, and one from Malaysia. Similar to reports of blindness with facial fillers, the most common injection site reported with this adverse effect was the glabella (five cases);
Other reports involved injections of the forehead (two), followed by the nasolabial fold (one), lateral canthus (one), and temporomandibular joint (one). Two of the seven patients received injections at more than one site, resulting in the total number of injections reported (10) being higher than the number of patients.
The risk of blindness is inherent with deep injection into a vessel that anastomoses with the blood supply to the eye. No mention was made as to whether PRP or platelet-rich fibrin was used. Other details are lacking from the original articles as to injection technique and whether or not cannula injection was used. No treatment was attempted in four of seven cases.
As plasma is native to the arteries and dissolves in the blood stream naturally, the mechanism as to why retinal artery occlusion or blindness would occur is not completely clear. One theory is that it is volume related and results from the speed of injection, causing a large rapid bolus that temporarily occludes or compresses an involved vessel.
Another theory is that damage to the vessel results from the injection itself or injection technique, leading to a clotting cascade and clot of the involved vessel with subsequent retrograde flow or blockade of the retinal artery. But if this were the case, we would expect to hear about more cases of clots leading to vascular occlusion or skin necrosis, which does not typically occur or we do not hear about.
Details about proper collection materials and technique or mixing with some other materials are also unknown in these cases, thus leaving the possibility that a more occlusive material may have been injected, as opposed to the fluid-like composition of the typical PRP preparation.With regards to risk with scalp PRP injection, the frontal scalp does receive blood supply from the supratrochlear artery that anastomoses with the angular artery of the face – both of which anastomose with the retinal artery (where occlusion would occur via back flow). The scalp tributaries are small and far enough away from the retina at that point that risk of back flow the to retinal artery should be minimal. Additionally, no reports of vascular occlusion from PRP scalp injection leading to skin necrosis have ever been reported. Of note, this is also not a risk that has been reported with the use of PRP with microneedling procedures, where PRP is placed on top of the skin before, during and after microneedling.
Anything that occludes the blood supply to the eye, whether it be fat, filler, or PRP, has an inherent risk of blindness. As there is no reversal agent or designated treatment for PRP occlusion, care must be taken to minimize risk, including awareness of anatomy and avoidance of injection into high risk areas, and cannula use where appropriate. Gentle, slow, low-volume administration, and when possible, use of a retrograde injection technique, may also be helpful.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
How does radiofrequency microneedling work?
Technology in the field of aesthetic dermatology continues to advance over time. Microneedling, largely used to improve textural changes of the skin associated with photoaging and acne scarring, has evolved over time from the use of dermarollers and microneedling skin pens to energy-based devices that deliver radiofrequency (RF) energy though microneedles that are used today.
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Unlike prior radiofrequency energy-based devices that deliver radiofrequency energy on the skin surface to allow bulk thermal energy (or heat) to stimulate collagen remodeling and tissue tightening, RF microneedling devices deliver the same RF or thermal energy via needles. RF, measured in Hertz (Hz) is part of the electromagnetic spectrum, with most devices delivering thermal energy at around 1-2 MHz, which is less than most typical RF only devices (at around 4-6 MHz), but with potentially more precise depth and delivery. For comparison, the RF of household electrical currents are around 60 Hz; traditional electrosurgical units, 50Hz -300 kHz; AM radio, 500 KHz; and microwaves, 2500 MHz.
When delivered to the skin, RF energy produces a change in the electrical charge of the skin, resulting in movement of electrons. The impedance (or resistance) of the tissue to the electron movement is what generates heat. Different factors, including tissue thickness, pressure applied to the tissue, hydration, bipolar versus monopolar delivery, and the number of needles are several factors than can affect the impedance.
Bipolar RF means that the current passes between two electrodes, whereas monopolar RF means that the electrical current is between an active treatment electrode and a passive grounding electrode (or grounding pad typically placed on the patient’s back). With bipolar RF, the current is limited to the area between the two electrodes. The depth of penetration is half of the distance between the electrodes, thus resulting in shallow (but potentially more aggressive) tissue heating. With monopolar RF, deeper tissue penetration occurs that is also often less uncomfortable to the patient.
The desired result of the energy delivery is collagen remodeling and strengthening of elastin. RF microneedling and microneedling in general may also have potential for use in enhancing topical product delivery.
Depending on the device, settings can be tailored to affect the energy delivery, including the type of needle (insulated vs. uninsulated vs. semi-insulated), Hz, number of needles, depth of needles, and time of exposure. In general, insulated needle tips provide less heat accumulation and potential injury to the skin surface, whereas uninsulated needles allow for more heat accumulation. Insulated needles, longer time of exposure, and lower energies (Hz) are safer options for darker skin types and those who hyperpigment easily.
Immediately after treatment, expected clinical endpoints can include erythema, edema, and possibly pinpoint bleeding that may last approximately several days to 2 weeks depending on the intensity of treatment. Potential side effects include infection, pigmentary alteration, folliculitis, prolonged grid marks, and scarring. Contraindications to treatment include having a pacemaker, history of keloid formation, active skin infections, prior gold threads in the treatment area, pregnancy and breastfeeding, metal implants in the treatment area, embedded electronic devices that cannot be turned off, isotretinoin use in the past 6 months, and allergy to any of the components of treatment.
Caution should be taken with tattoos in the treatment area or grounding pad (including cosmetic tattoos as tattoo ink may often contain metals that may absorb some of the heat, increasing the risk for injury or extrusion of the ink), a history of cold sores or herpes simplex virus in the treatment area (if so, a prophylactic antiviral would be indicated prior to treatment), use of topical retinoids in the past 7 days, having received neurotoxin or fillers in the prior 2 weeks, autoimmune disease, bleeding disorders, neuropathy, and history of poor healing.
Depending on the device and area being treated, most RF microneedling treatments require two to five treatments, typically 4-6 weeks apart. If improvement is seen, it may be noticeable after one to two treatments, and as with laser resurfacing, continued improvement may be noticeable over the following 6-12 months post treatment.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley has no relevant disclosures.
Technology in the field of aesthetic dermatology continues to advance over time. Microneedling, largely used to improve textural changes of the skin associated with photoaging and acne scarring, has evolved over time from the use of dermarollers and microneedling skin pens to energy-based devices that deliver radiofrequency (RF) energy though microneedles that are used today.
.
Unlike prior radiofrequency energy-based devices that deliver radiofrequency energy on the skin surface to allow bulk thermal energy (or heat) to stimulate collagen remodeling and tissue tightening, RF microneedling devices deliver the same RF or thermal energy via needles. RF, measured in Hertz (Hz) is part of the electromagnetic spectrum, with most devices delivering thermal energy at around 1-2 MHz, which is less than most typical RF only devices (at around 4-6 MHz), but with potentially more precise depth and delivery. For comparison, the RF of household electrical currents are around 60 Hz; traditional electrosurgical units, 50Hz -300 kHz; AM radio, 500 KHz; and microwaves, 2500 MHz.
When delivered to the skin, RF energy produces a change in the electrical charge of the skin, resulting in movement of electrons. The impedance (or resistance) of the tissue to the electron movement is what generates heat. Different factors, including tissue thickness, pressure applied to the tissue, hydration, bipolar versus monopolar delivery, and the number of needles are several factors than can affect the impedance.
Bipolar RF means that the current passes between two electrodes, whereas monopolar RF means that the electrical current is between an active treatment electrode and a passive grounding electrode (or grounding pad typically placed on the patient’s back). With bipolar RF, the current is limited to the area between the two electrodes. The depth of penetration is half of the distance between the electrodes, thus resulting in shallow (but potentially more aggressive) tissue heating. With monopolar RF, deeper tissue penetration occurs that is also often less uncomfortable to the patient.
The desired result of the energy delivery is collagen remodeling and strengthening of elastin. RF microneedling and microneedling in general may also have potential for use in enhancing topical product delivery.
Depending on the device, settings can be tailored to affect the energy delivery, including the type of needle (insulated vs. uninsulated vs. semi-insulated), Hz, number of needles, depth of needles, and time of exposure. In general, insulated needle tips provide less heat accumulation and potential injury to the skin surface, whereas uninsulated needles allow for more heat accumulation. Insulated needles, longer time of exposure, and lower energies (Hz) are safer options for darker skin types and those who hyperpigment easily.
Immediately after treatment, expected clinical endpoints can include erythema, edema, and possibly pinpoint bleeding that may last approximately several days to 2 weeks depending on the intensity of treatment. Potential side effects include infection, pigmentary alteration, folliculitis, prolonged grid marks, and scarring. Contraindications to treatment include having a pacemaker, history of keloid formation, active skin infections, prior gold threads in the treatment area, pregnancy and breastfeeding, metal implants in the treatment area, embedded electronic devices that cannot be turned off, isotretinoin use in the past 6 months, and allergy to any of the components of treatment.
Caution should be taken with tattoos in the treatment area or grounding pad (including cosmetic tattoos as tattoo ink may often contain metals that may absorb some of the heat, increasing the risk for injury or extrusion of the ink), a history of cold sores or herpes simplex virus in the treatment area (if so, a prophylactic antiviral would be indicated prior to treatment), use of topical retinoids in the past 7 days, having received neurotoxin or fillers in the prior 2 weeks, autoimmune disease, bleeding disorders, neuropathy, and history of poor healing.
Depending on the device and area being treated, most RF microneedling treatments require two to five treatments, typically 4-6 weeks apart. If improvement is seen, it may be noticeable after one to two treatments, and as with laser resurfacing, continued improvement may be noticeable over the following 6-12 months post treatment.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley has no relevant disclosures.
Technology in the field of aesthetic dermatology continues to advance over time. Microneedling, largely used to improve textural changes of the skin associated with photoaging and acne scarring, has evolved over time from the use of dermarollers and microneedling skin pens to energy-based devices that deliver radiofrequency (RF) energy though microneedles that are used today.
.
Unlike prior radiofrequency energy-based devices that deliver radiofrequency energy on the skin surface to allow bulk thermal energy (or heat) to stimulate collagen remodeling and tissue tightening, RF microneedling devices deliver the same RF or thermal energy via needles. RF, measured in Hertz (Hz) is part of the electromagnetic spectrum, with most devices delivering thermal energy at around 1-2 MHz, which is less than most typical RF only devices (at around 4-6 MHz), but with potentially more precise depth and delivery. For comparison, the RF of household electrical currents are around 60 Hz; traditional electrosurgical units, 50Hz -300 kHz; AM radio, 500 KHz; and microwaves, 2500 MHz.
When delivered to the skin, RF energy produces a change in the electrical charge of the skin, resulting in movement of electrons. The impedance (or resistance) of the tissue to the electron movement is what generates heat. Different factors, including tissue thickness, pressure applied to the tissue, hydration, bipolar versus monopolar delivery, and the number of needles are several factors than can affect the impedance.
Bipolar RF means that the current passes between two electrodes, whereas monopolar RF means that the electrical current is between an active treatment electrode and a passive grounding electrode (or grounding pad typically placed on the patient’s back). With bipolar RF, the current is limited to the area between the two electrodes. The depth of penetration is half of the distance between the electrodes, thus resulting in shallow (but potentially more aggressive) tissue heating. With monopolar RF, deeper tissue penetration occurs that is also often less uncomfortable to the patient.
The desired result of the energy delivery is collagen remodeling and strengthening of elastin. RF microneedling and microneedling in general may also have potential for use in enhancing topical product delivery.
Depending on the device, settings can be tailored to affect the energy delivery, including the type of needle (insulated vs. uninsulated vs. semi-insulated), Hz, number of needles, depth of needles, and time of exposure. In general, insulated needle tips provide less heat accumulation and potential injury to the skin surface, whereas uninsulated needles allow for more heat accumulation. Insulated needles, longer time of exposure, and lower energies (Hz) are safer options for darker skin types and those who hyperpigment easily.
Immediately after treatment, expected clinical endpoints can include erythema, edema, and possibly pinpoint bleeding that may last approximately several days to 2 weeks depending on the intensity of treatment. Potential side effects include infection, pigmentary alteration, folliculitis, prolonged grid marks, and scarring. Contraindications to treatment include having a pacemaker, history of keloid formation, active skin infections, prior gold threads in the treatment area, pregnancy and breastfeeding, metal implants in the treatment area, embedded electronic devices that cannot be turned off, isotretinoin use in the past 6 months, and allergy to any of the components of treatment.
Caution should be taken with tattoos in the treatment area or grounding pad (including cosmetic tattoos as tattoo ink may often contain metals that may absorb some of the heat, increasing the risk for injury or extrusion of the ink), a history of cold sores or herpes simplex virus in the treatment area (if so, a prophylactic antiviral would be indicated prior to treatment), use of topical retinoids in the past 7 days, having received neurotoxin or fillers in the prior 2 weeks, autoimmune disease, bleeding disorders, neuropathy, and history of poor healing.
Depending on the device and area being treated, most RF microneedling treatments require two to five treatments, typically 4-6 weeks apart. If improvement is seen, it may be noticeable after one to two treatments, and as with laser resurfacing, continued improvement may be noticeable over the following 6-12 months post treatment.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley has no relevant disclosures.
20th anniversary and history of cosmetic botulinum toxin type A
The timeline of botulinum toxin discovery began with deadly outbreaks related to contaminated food across Europe in the late 1700s, the largest of which occurred in 1793 in Wildebrad, in southern Germany. In 1811, “prussic acid” was named as the culprit in what was referred to as sausage poisoning. Between 1817 and 1822, German physician Justinus Kerner noted that the active substance interrupted signals from motor nerves to muscles, but spared sensory and cognitive abilities, accurately describing botulism. He hypothesized that this substance could possibly be used as treatment for medical conditions when ingested orally. It wasn’t until 1895 that microbiologist Emile Pierre Van Ermengem, a professor of bacteriology in Belgium, identified the bacterium responsible as Bacillus botulinus, later renamed C. botulinum.
In 1905, it was discovered that C. botulinum produced a substance that affected neurotransmitter function, and between 1895 and 1915, seven toxin serotypes were recognized. In 1928, Herman Sommer, PhD, at the Hooper Foundation, at the University of California, San Francisco, isolated the most potent serotype: botulinum toxin type A (BoNT-A).
In 1946, Carl Lamanna and James Duff developed concentration and crystallization techniques that were subsequently used by Edward Schantz, PhD, at Fort Detrick, Md., for a possible biologic weapon. In 1972, Dr. Schantz took his research to the University of Wisconsin, where he produced a large batch of BoNT-A that remained in clinical use until December 1997.
In the late 1960s and early 1970s, an ophthalmologist in San Francisco, Alan Scott, MD, began animal studies with BoNT-A supplied by Dr. Schantz, as a possible treatment for strabismus, publishing his first report of BoNT-A in primates in 1973. In 1978, the Food and Drug Administration granted approval to begin testing small amounts of the toxin in human volunteers. In 1980, a landmark paper was published demonstrating that BoNT-A corrects gaze misalignment in humans. By 1989, it was approved as Oculinum by the FDA for the treatment of strabismus and blepharospasm.
Keen clinical observation and a serendipitous discovery led to botulinum toxin’s first uses for cosmetic purposes. In the mid-1980s, Jean Carruthers, MD, an ophthalmologist in Vancouver, noted an unexpected concomitant improvement of glabellar rhytids in a patient treated with BoNT for blepharospasm. The result of the treatment was a more serene, untroubled expression. Dr. Carruthers discussed the observation with her dermatologist spouse, Alastair Carruthers, MD, who was attempting to use soft tissue–augmenting agents available at the time to soften forehead wrinkles. Intrigued by the possibilities, the Carruthers subsequently injected a small amount of BoNT-A between the eyebrows of their assistant, Cathy Bickerton Swann, also now known as “patient zero” and awaited the results.
Seventeen additional patients followed, aged 34-51, who collectively, would become part of the first report on the efficacy of BoNT-A for cosmetic use – for the treatment of glabellar frown lines – published in 1992.
Between 1992 and 1997, the popularity of off-label use of BoNT-A grew so rapidly that Allergan’s supply temporarily ran out. By 2002, safety and efficacy profiles of use in medical conditions such as strabismus, blepharospasm, hemifacial spasm, cervical dystonia, cerebral palsy, poststroke spasticity, hyperhidrosis, headache, and back pain had been well-established, facilitating the comfort and use for cosmetic purposes.
By 2002, open-label studies of more than 800 patients confirmed the efficacy and safety of BoNT for the treatment of dynamic facial rhytids. And in April 2002, the FDA granted approval of BoNT for the nonsurgical reduction of glabellar rhytids. The rest, some would say, is history. On this 20th-year anniversary of the approval of botulinum toxin for cosmetic use, special recognition is given here for the physicians and scientists who were astute enough to make this discovery, as botulinum toxin use remains one of the most popular and effective nonsurgical cosmetic procedures today.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley disclosed that she has been a clinical investigator and consultant for Botox manufacturer Allergan in the past, and manufacturers of other brands of botulinum toxins available for cosmetic use; Dysport (Galderma), Xeomin (Merz), and Jeuveau (Evolus). Dr. Talakoub had no disclosures.
Reference
“Botulinum Toxin: Procedures in Cosmetic Dermatology Series 3rd Edition” (Philadelphia: Saunders Elsevier, 2013)
The timeline of botulinum toxin discovery began with deadly outbreaks related to contaminated food across Europe in the late 1700s, the largest of which occurred in 1793 in Wildebrad, in southern Germany. In 1811, “prussic acid” was named as the culprit in what was referred to as sausage poisoning. Between 1817 and 1822, German physician Justinus Kerner noted that the active substance interrupted signals from motor nerves to muscles, but spared sensory and cognitive abilities, accurately describing botulism. He hypothesized that this substance could possibly be used as treatment for medical conditions when ingested orally. It wasn’t until 1895 that microbiologist Emile Pierre Van Ermengem, a professor of bacteriology in Belgium, identified the bacterium responsible as Bacillus botulinus, later renamed C. botulinum.
In 1905, it was discovered that C. botulinum produced a substance that affected neurotransmitter function, and between 1895 and 1915, seven toxin serotypes were recognized. In 1928, Herman Sommer, PhD, at the Hooper Foundation, at the University of California, San Francisco, isolated the most potent serotype: botulinum toxin type A (BoNT-A).
In 1946, Carl Lamanna and James Duff developed concentration and crystallization techniques that were subsequently used by Edward Schantz, PhD, at Fort Detrick, Md., for a possible biologic weapon. In 1972, Dr. Schantz took his research to the University of Wisconsin, where he produced a large batch of BoNT-A that remained in clinical use until December 1997.
In the late 1960s and early 1970s, an ophthalmologist in San Francisco, Alan Scott, MD, began animal studies with BoNT-A supplied by Dr. Schantz, as a possible treatment for strabismus, publishing his first report of BoNT-A in primates in 1973. In 1978, the Food and Drug Administration granted approval to begin testing small amounts of the toxin in human volunteers. In 1980, a landmark paper was published demonstrating that BoNT-A corrects gaze misalignment in humans. By 1989, it was approved as Oculinum by the FDA for the treatment of strabismus and blepharospasm.
Keen clinical observation and a serendipitous discovery led to botulinum toxin’s first uses for cosmetic purposes. In the mid-1980s, Jean Carruthers, MD, an ophthalmologist in Vancouver, noted an unexpected concomitant improvement of glabellar rhytids in a patient treated with BoNT for blepharospasm. The result of the treatment was a more serene, untroubled expression. Dr. Carruthers discussed the observation with her dermatologist spouse, Alastair Carruthers, MD, who was attempting to use soft tissue–augmenting agents available at the time to soften forehead wrinkles. Intrigued by the possibilities, the Carruthers subsequently injected a small amount of BoNT-A between the eyebrows of their assistant, Cathy Bickerton Swann, also now known as “patient zero” and awaited the results.
Seventeen additional patients followed, aged 34-51, who collectively, would become part of the first report on the efficacy of BoNT-A for cosmetic use – for the treatment of glabellar frown lines – published in 1992.
Between 1992 and 1997, the popularity of off-label use of BoNT-A grew so rapidly that Allergan’s supply temporarily ran out. By 2002, safety and efficacy profiles of use in medical conditions such as strabismus, blepharospasm, hemifacial spasm, cervical dystonia, cerebral palsy, poststroke spasticity, hyperhidrosis, headache, and back pain had been well-established, facilitating the comfort and use for cosmetic purposes.
By 2002, open-label studies of more than 800 patients confirmed the efficacy and safety of BoNT for the treatment of dynamic facial rhytids. And in April 2002, the FDA granted approval of BoNT for the nonsurgical reduction of glabellar rhytids. The rest, some would say, is history. On this 20th-year anniversary of the approval of botulinum toxin for cosmetic use, special recognition is given here for the physicians and scientists who were astute enough to make this discovery, as botulinum toxin use remains one of the most popular and effective nonsurgical cosmetic procedures today.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley disclosed that she has been a clinical investigator and consultant for Botox manufacturer Allergan in the past, and manufacturers of other brands of botulinum toxins available for cosmetic use; Dysport (Galderma), Xeomin (Merz), and Jeuveau (Evolus). Dr. Talakoub had no disclosures.
Reference
“Botulinum Toxin: Procedures in Cosmetic Dermatology Series 3rd Edition” (Philadelphia: Saunders Elsevier, 2013)
The timeline of botulinum toxin discovery began with deadly outbreaks related to contaminated food across Europe in the late 1700s, the largest of which occurred in 1793 in Wildebrad, in southern Germany. In 1811, “prussic acid” was named as the culprit in what was referred to as sausage poisoning. Between 1817 and 1822, German physician Justinus Kerner noted that the active substance interrupted signals from motor nerves to muscles, but spared sensory and cognitive abilities, accurately describing botulism. He hypothesized that this substance could possibly be used as treatment for medical conditions when ingested orally. It wasn’t until 1895 that microbiologist Emile Pierre Van Ermengem, a professor of bacteriology in Belgium, identified the bacterium responsible as Bacillus botulinus, later renamed C. botulinum.
In 1905, it was discovered that C. botulinum produced a substance that affected neurotransmitter function, and between 1895 and 1915, seven toxin serotypes were recognized. In 1928, Herman Sommer, PhD, at the Hooper Foundation, at the University of California, San Francisco, isolated the most potent serotype: botulinum toxin type A (BoNT-A).
In 1946, Carl Lamanna and James Duff developed concentration and crystallization techniques that were subsequently used by Edward Schantz, PhD, at Fort Detrick, Md., for a possible biologic weapon. In 1972, Dr. Schantz took his research to the University of Wisconsin, where he produced a large batch of BoNT-A that remained in clinical use until December 1997.
In the late 1960s and early 1970s, an ophthalmologist in San Francisco, Alan Scott, MD, began animal studies with BoNT-A supplied by Dr. Schantz, as a possible treatment for strabismus, publishing his first report of BoNT-A in primates in 1973. In 1978, the Food and Drug Administration granted approval to begin testing small amounts of the toxin in human volunteers. In 1980, a landmark paper was published demonstrating that BoNT-A corrects gaze misalignment in humans. By 1989, it was approved as Oculinum by the FDA for the treatment of strabismus and blepharospasm.
Keen clinical observation and a serendipitous discovery led to botulinum toxin’s first uses for cosmetic purposes. In the mid-1980s, Jean Carruthers, MD, an ophthalmologist in Vancouver, noted an unexpected concomitant improvement of glabellar rhytids in a patient treated with BoNT for blepharospasm. The result of the treatment was a more serene, untroubled expression. Dr. Carruthers discussed the observation with her dermatologist spouse, Alastair Carruthers, MD, who was attempting to use soft tissue–augmenting agents available at the time to soften forehead wrinkles. Intrigued by the possibilities, the Carruthers subsequently injected a small amount of BoNT-A between the eyebrows of their assistant, Cathy Bickerton Swann, also now known as “patient zero” and awaited the results.
Seventeen additional patients followed, aged 34-51, who collectively, would become part of the first report on the efficacy of BoNT-A for cosmetic use – for the treatment of glabellar frown lines – published in 1992.
Between 1992 and 1997, the popularity of off-label use of BoNT-A grew so rapidly that Allergan’s supply temporarily ran out. By 2002, safety and efficacy profiles of use in medical conditions such as strabismus, blepharospasm, hemifacial spasm, cervical dystonia, cerebral palsy, poststroke spasticity, hyperhidrosis, headache, and back pain had been well-established, facilitating the comfort and use for cosmetic purposes.
By 2002, open-label studies of more than 800 patients confirmed the efficacy and safety of BoNT for the treatment of dynamic facial rhytids. And in April 2002, the FDA granted approval of BoNT for the nonsurgical reduction of glabellar rhytids. The rest, some would say, is history. On this 20th-year anniversary of the approval of botulinum toxin for cosmetic use, special recognition is given here for the physicians and scientists who were astute enough to make this discovery, as botulinum toxin use remains one of the most popular and effective nonsurgical cosmetic procedures today.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. Dr. Wesley disclosed that she has been a clinical investigator and consultant for Botox manufacturer Allergan in the past, and manufacturers of other brands of botulinum toxins available for cosmetic use; Dysport (Galderma), Xeomin (Merz), and Jeuveau (Evolus). Dr. Talakoub had no disclosures.
Reference
“Botulinum Toxin: Procedures in Cosmetic Dermatology Series 3rd Edition” (Philadelphia: Saunders Elsevier, 2013)
Mercury and other risks of cosmetic skin lighteners
Skin hyperpigmentation – whether it is caused by postinflammatory hyperpigmentation from acne or trauma to the skin, melasma, autoimmune disorders, or disorders of pigmentation – is a condition where treatment is commonly sought after in dermatology offices. Topical products used to fade hyperpigmented areas of the skin have long been used around the world, and because of safety concerns, regulations aimed at reducing potential harm or adverse effects caused by certain ingredients in these products are increasing in different countries.
For example, while extremely effective at treating most forms of hyperpigmentation, hydroquinone has been definitively linked to ochronosis, kojic acid has been linked to contact dermatitis in humans, and acid peels and retinoids are associated with irritant dermatitis, disruption of the skin barrier, and photosensitivity. In animal studies, licorice root extract has been linked to endocrine and other organ system irregularities.
Kojic acid was banned in Japan in 2003, and subsequently in South Korea and Switzerland because of concerns over animal studies indicating that its fungal metabolite might be carcinogenic (. Hydroquinone is classified as a drug and has been banned for use in cosmetic products in Japan, the European Union, Australia, and several African nations since at least 2006 because of concerns over adrenal gland dysregulation and high levels of mercury in hydroquinone products in those countries. In Africa specifically, South Africa banned all but 2% hydroquinone in 1983, the Ivory Coast banned all skin whitening creams in 2015, and in 2016, Ghana initiated a ban on certain skin products containing hydroquinone.
The United States followed suit in February 2020 with the Food and Drug Administration introducing a ban on all OTC hydroquinone-containing products because of concerns over carcinogenicity in animal studies (which has not been shown in human studies to date). The “Coronavirus Aid, Relief, and Economic Security” (CARES) Act signed in March 2020 then made the changes effective by halting the sale of OTC hydroquinone products in the United States as of September 2020.
Mercury concerns
Despite these bans, hydroquinone continues to be sold in cosmetics and OTC products around the world and online. And despite being banned or limited in these products, in particular. Mercury has been used in cosmetic products as a skin lightening agent (on its own) and as a preservative.
Mercury has been shown to be carcinogenic, neurotoxic, as well as cytotoxic to the renal and endocrine systems, causes reproductive toxicity, and may be bioaccumulative in wildlife and humans. There is particular concern regarding the risks of exposure in pregnant women and babies because of potential harm to the developing brain and nervous system. Initial signs and symptoms of mercury poisoning include irritability, shyness, tremors, changes in vision or hearing, memory problems, depression, numbness and tingling in the hands, feet, or around the mouth.
Organizations such as the Zero Mercury Working Group (ZMWG) – an international coalition of public interest environmental and health nongovernmental organizations from more than 55 countries, focused on eliminating the use, release, and exposure to mercury – have been working to help ensure safety and mercury levels are below the threshold deemed allowable in hydroquinone-containing products.
On March 10, the ZMWG published the results of a new study demonstrating that skin lighteners containing mercury are still being sold online, despite bans and safety concerns. Ebay, Amazon, Shopee, Jiji, and Flipkart are among the websites still selling high mercury–containing skin lightener products. Some of them were the same offenders selling the banned products in 2019. Of the 271 online products tested from 17 countries, nearly half contained over 1 ppm of mercury, which is the legal limit that has been established by most governments and the Minamata Convention on Mercury. Based on their packaging, the majority of these products were manufactured in Asia, most often in Pakistan (43%), Thailand (8%), China (6%), and Taiwan (4%), according to the report.
In ZMWG’s prior publications, mercury concentrations reported in some of these products ranged from 93 ppm to over 16,000 ppm. Even higher concentrations have been reported by other entities. And according to a World Health Organization November 2019 report, mercury-containing skin lightening products have been manufactured in many countries and areas, including Bangladesh, China, Dominican Republic Hong Kong SAR (China), Jamaica, Lebanon, Malaysia, Mexico, Pakistan, Philippines, Republic of Korea, Thailand, and the United States. According to the ZMWG, 137 countries have committed to the Minamata Convention to phase out and limit mercury, including in cosmetics.
Despite bans on some of these products, consumers in the United States and other countries with bans and restrictions are still at risk of exposure to mercury-containing skin lighteners because of online sales. Hopefully, the work of the ZMWG and similar entities will continue to help limit potentially harmful exposures to mercury, while maintaining access to safe and effective methods to treat hyperpigmentation.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Skin hyperpigmentation – whether it is caused by postinflammatory hyperpigmentation from acne or trauma to the skin, melasma, autoimmune disorders, or disorders of pigmentation – is a condition where treatment is commonly sought after in dermatology offices. Topical products used to fade hyperpigmented areas of the skin have long been used around the world, and because of safety concerns, regulations aimed at reducing potential harm or adverse effects caused by certain ingredients in these products are increasing in different countries.
For example, while extremely effective at treating most forms of hyperpigmentation, hydroquinone has been definitively linked to ochronosis, kojic acid has been linked to contact dermatitis in humans, and acid peels and retinoids are associated with irritant dermatitis, disruption of the skin barrier, and photosensitivity. In animal studies, licorice root extract has been linked to endocrine and other organ system irregularities.
Kojic acid was banned in Japan in 2003, and subsequently in South Korea and Switzerland because of concerns over animal studies indicating that its fungal metabolite might be carcinogenic (. Hydroquinone is classified as a drug and has been banned for use in cosmetic products in Japan, the European Union, Australia, and several African nations since at least 2006 because of concerns over adrenal gland dysregulation and high levels of mercury in hydroquinone products in those countries. In Africa specifically, South Africa banned all but 2% hydroquinone in 1983, the Ivory Coast banned all skin whitening creams in 2015, and in 2016, Ghana initiated a ban on certain skin products containing hydroquinone.
The United States followed suit in February 2020 with the Food and Drug Administration introducing a ban on all OTC hydroquinone-containing products because of concerns over carcinogenicity in animal studies (which has not been shown in human studies to date). The “Coronavirus Aid, Relief, and Economic Security” (CARES) Act signed in March 2020 then made the changes effective by halting the sale of OTC hydroquinone products in the United States as of September 2020.
Mercury concerns
Despite these bans, hydroquinone continues to be sold in cosmetics and OTC products around the world and online. And despite being banned or limited in these products, in particular. Mercury has been used in cosmetic products as a skin lightening agent (on its own) and as a preservative.
Mercury has been shown to be carcinogenic, neurotoxic, as well as cytotoxic to the renal and endocrine systems, causes reproductive toxicity, and may be bioaccumulative in wildlife and humans. There is particular concern regarding the risks of exposure in pregnant women and babies because of potential harm to the developing brain and nervous system. Initial signs and symptoms of mercury poisoning include irritability, shyness, tremors, changes in vision or hearing, memory problems, depression, numbness and tingling in the hands, feet, or around the mouth.
Organizations such as the Zero Mercury Working Group (ZMWG) – an international coalition of public interest environmental and health nongovernmental organizations from more than 55 countries, focused on eliminating the use, release, and exposure to mercury – have been working to help ensure safety and mercury levels are below the threshold deemed allowable in hydroquinone-containing products.
On March 10, the ZMWG published the results of a new study demonstrating that skin lighteners containing mercury are still being sold online, despite bans and safety concerns. Ebay, Amazon, Shopee, Jiji, and Flipkart are among the websites still selling high mercury–containing skin lightener products. Some of them were the same offenders selling the banned products in 2019. Of the 271 online products tested from 17 countries, nearly half contained over 1 ppm of mercury, which is the legal limit that has been established by most governments and the Minamata Convention on Mercury. Based on their packaging, the majority of these products were manufactured in Asia, most often in Pakistan (43%), Thailand (8%), China (6%), and Taiwan (4%), according to the report.
In ZMWG’s prior publications, mercury concentrations reported in some of these products ranged from 93 ppm to over 16,000 ppm. Even higher concentrations have been reported by other entities. And according to a World Health Organization November 2019 report, mercury-containing skin lightening products have been manufactured in many countries and areas, including Bangladesh, China, Dominican Republic Hong Kong SAR (China), Jamaica, Lebanon, Malaysia, Mexico, Pakistan, Philippines, Republic of Korea, Thailand, and the United States. According to the ZMWG, 137 countries have committed to the Minamata Convention to phase out and limit mercury, including in cosmetics.
Despite bans on some of these products, consumers in the United States and other countries with bans and restrictions are still at risk of exposure to mercury-containing skin lighteners because of online sales. Hopefully, the work of the ZMWG and similar entities will continue to help limit potentially harmful exposures to mercury, while maintaining access to safe and effective methods to treat hyperpigmentation.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Skin hyperpigmentation – whether it is caused by postinflammatory hyperpigmentation from acne or trauma to the skin, melasma, autoimmune disorders, or disorders of pigmentation – is a condition where treatment is commonly sought after in dermatology offices. Topical products used to fade hyperpigmented areas of the skin have long been used around the world, and because of safety concerns, regulations aimed at reducing potential harm or adverse effects caused by certain ingredients in these products are increasing in different countries.
For example, while extremely effective at treating most forms of hyperpigmentation, hydroquinone has been definitively linked to ochronosis, kojic acid has been linked to contact dermatitis in humans, and acid peels and retinoids are associated with irritant dermatitis, disruption of the skin barrier, and photosensitivity. In animal studies, licorice root extract has been linked to endocrine and other organ system irregularities.
Kojic acid was banned in Japan in 2003, and subsequently in South Korea and Switzerland because of concerns over animal studies indicating that its fungal metabolite might be carcinogenic (. Hydroquinone is classified as a drug and has been banned for use in cosmetic products in Japan, the European Union, Australia, and several African nations since at least 2006 because of concerns over adrenal gland dysregulation and high levels of mercury in hydroquinone products in those countries. In Africa specifically, South Africa banned all but 2% hydroquinone in 1983, the Ivory Coast banned all skin whitening creams in 2015, and in 2016, Ghana initiated a ban on certain skin products containing hydroquinone.
The United States followed suit in February 2020 with the Food and Drug Administration introducing a ban on all OTC hydroquinone-containing products because of concerns over carcinogenicity in animal studies (which has not been shown in human studies to date). The “Coronavirus Aid, Relief, and Economic Security” (CARES) Act signed in March 2020 then made the changes effective by halting the sale of OTC hydroquinone products in the United States as of September 2020.
Mercury concerns
Despite these bans, hydroquinone continues to be sold in cosmetics and OTC products around the world and online. And despite being banned or limited in these products, in particular. Mercury has been used in cosmetic products as a skin lightening agent (on its own) and as a preservative.
Mercury has been shown to be carcinogenic, neurotoxic, as well as cytotoxic to the renal and endocrine systems, causes reproductive toxicity, and may be bioaccumulative in wildlife and humans. There is particular concern regarding the risks of exposure in pregnant women and babies because of potential harm to the developing brain and nervous system. Initial signs and symptoms of mercury poisoning include irritability, shyness, tremors, changes in vision or hearing, memory problems, depression, numbness and tingling in the hands, feet, or around the mouth.
Organizations such as the Zero Mercury Working Group (ZMWG) – an international coalition of public interest environmental and health nongovernmental organizations from more than 55 countries, focused on eliminating the use, release, and exposure to mercury – have been working to help ensure safety and mercury levels are below the threshold deemed allowable in hydroquinone-containing products.
On March 10, the ZMWG published the results of a new study demonstrating that skin lighteners containing mercury are still being sold online, despite bans and safety concerns. Ebay, Amazon, Shopee, Jiji, and Flipkart are among the websites still selling high mercury–containing skin lightener products. Some of them were the same offenders selling the banned products in 2019. Of the 271 online products tested from 17 countries, nearly half contained over 1 ppm of mercury, which is the legal limit that has been established by most governments and the Minamata Convention on Mercury. Based on their packaging, the majority of these products were manufactured in Asia, most often in Pakistan (43%), Thailand (8%), China (6%), and Taiwan (4%), according to the report.
In ZMWG’s prior publications, mercury concentrations reported in some of these products ranged from 93 ppm to over 16,000 ppm. Even higher concentrations have been reported by other entities. And according to a World Health Organization November 2019 report, mercury-containing skin lightening products have been manufactured in many countries and areas, including Bangladesh, China, Dominican Republic Hong Kong SAR (China), Jamaica, Lebanon, Malaysia, Mexico, Pakistan, Philippines, Republic of Korea, Thailand, and the United States. According to the ZMWG, 137 countries have committed to the Minamata Convention to phase out and limit mercury, including in cosmetics.
Despite bans on some of these products, consumers in the United States and other countries with bans and restrictions are still at risk of exposure to mercury-containing skin lighteners because of online sales. Hopefully, the work of the ZMWG and similar entities will continue to help limit potentially harmful exposures to mercury, while maintaining access to safe and effective methods to treat hyperpigmentation.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Clay minerals and the skin
Natural clay from the earth and its minerals, imperative for survival of life on our planet, have been used for medicinal purposes for thousands of years. , and for some, the environmental and sustainability viewpoint that minerals will not harm the environment after disposal.
Clay minerals namely consist of silica, alumina, and/or magnesia, and sometimes varying degrees of iron, sodium, potassium, calcium, and water. Depending on the type of clay, as many as 75 trace minerals may be present.
Ochre
The first uses of ochre, or natural clay earth pigment, are thought to be by Homo erectus and Homo neanderthalensis who used ochre with water to soothe irritations, heal wounds, and clean skin. The theory is that they mimicked some animals who instinctively used clay/mud/minerals in this manner.
The first recorded use of medicinal clay is on Mesopotamian clay tablets, dating to about 2500 B.C. The ancient Egyptian physicians used clays as anti-inflammatory agents and antiseptics. Clay was also used as a preservative during mummification.
Throughout history, clay has been used for dermatologic purposes. Aristotle (384-322 BC) made one of the first references to deliberately eating clay, earth, or soil by humans for therapeutic and religious purposes. Later, Marco Polo described in his travels seeing Muslim pilgrims cure fevers by ingesting “pink earth.”
The ochres have also long been found in indigenous and aboriginal art, and in current day Namibia, the Himba tribe have used Otjize paste (bright red clay consisting of butterfat, red ochre, and sometimes herbs) for their characteristic hairstyles and makeup, as well as for skin protection and as a soap replacement. Otjize is sacred to the culture and ethnic identity, signifying the beauty of their hair and skin and a sense of oneness with their surroundings (the earth). There are also many instances of religious, folklore, or mythological references of creation of life or creation of humankind from clay.
Dermatologic uses
The most common uses of clay in dermatology are for treatment of acne and in spa or cosmeceutical preparations to purportedly draw out dirt, impurities, or toxins.
Clay minerals are most commonly formed from prolonged chemical weathering of silicate-bearing rocks. Clay can also be formed from hydrothermal or volcanic activity. Chemical weathering takes place mainly by acid hydrolysis resulting from low concentrations of carbonic acid, dissolved in rainwater or released by plant roots. Clays differ in composition and structure depending upon the source. Simplistically, clay is structured in two layers, organized in various shapes, with varying minerals and electrical charges. The electric charge of clay allows the adsorption of various minerals, water, heavy and radioactive metals, free radicals, and other potentially unwanted byproducts of metabolic activity. With antibacterial properties and adsorptive properties, clay is often used to dry out acne or oily skin and/or to improve the appearance of large pores.
Bentonite clay
Bentonite clay is one of the most common forms of clay used in topical skin products. Bentonite clay, formed after volcanic ash has weathered and aged in the presence of water, is named after a formation called Benton Shale in the western United States. Bentonite has a strong negative electromagnetic charge and when mixed with water it swells like a sponge and can absorb 40-50 times its weight.
There are several types of Bentonite clay, named from the dominant element found within: Sodium bentonite, calcium bentonite, aluminum bentonite, and potassium bentonite are the most common. Bentonite clay is most commonly found in off-white or green colors.
Kaolin and red clay
Typically white or nearly white to sometimes gray in color, kaolin clay is one of the other most common types of clay used in skin care. While the minerals of the kaolin group display a relatively small specific surface area, compared with those of other clay groups, they can still adsorb small molecules, proteins, bacteria, and viruses on the surface of their particles.
Red clay, also sometimes seen in skin care, takes on its color because of a higher content of iron oxides.
In a 2011 study, Valenti et al. evaluated the impact of daily application of clay and retinoic acid 0.025% on the skin of rats.After 7 days, skin where clay had been applied showed a significant increase in collagen fibers, compared with control skin, while areas where retinoic acid had been applied did not show a significant increase in collagen fibers, compared with control skin.2
A recently published study claims that pH and its interaction with the clay particle surface charge may neutralize and impact properties – including antibacterial properties – of clay and is more significant than previously thought.3 The authors emphasize the dangers of this possibility with unregulated marketing and unsubstantiated bioceutical claims of products that contain clay. Many clay-based skin care products on the market today include other ingredients such as acids (for example salicylic acid, lactic acid, and malic acid) that may potentially counteract this issue and help enhance the targeted efficacy of the product.
The types and characteristics of all types of clay go beyond the scope of this column, but as demonstrated throughout history, clay may have a role in medicinal and dermatologic care, the research of which is still ongoing and is important in our understanding of how this earthly compound can affect our bodies.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1: Moraes JDD et al. Int J Pharm. 2017 Dec 20;534(1-2):213-219. doi: 10.1016/j.ijpharm.2017.10.031.
2: Valenti DMZ et al. Clin Exp Dermatol. 2012 Mar;37(2):164-8. doi: 10.1111/j.1365-2230.2011.04216.x
3. Incledion A et al. Biomolecules. 2021 Jan 5;11(1):58. doi: 10.3390/biom11010058.
Natural clay from the earth and its minerals, imperative for survival of life on our planet, have been used for medicinal purposes for thousands of years. , and for some, the environmental and sustainability viewpoint that minerals will not harm the environment after disposal.
Clay minerals namely consist of silica, alumina, and/or magnesia, and sometimes varying degrees of iron, sodium, potassium, calcium, and water. Depending on the type of clay, as many as 75 trace minerals may be present.
Ochre
The first uses of ochre, or natural clay earth pigment, are thought to be by Homo erectus and Homo neanderthalensis who used ochre with water to soothe irritations, heal wounds, and clean skin. The theory is that they mimicked some animals who instinctively used clay/mud/minerals in this manner.
The first recorded use of medicinal clay is on Mesopotamian clay tablets, dating to about 2500 B.C. The ancient Egyptian physicians used clays as anti-inflammatory agents and antiseptics. Clay was also used as a preservative during mummification.
Throughout history, clay has been used for dermatologic purposes. Aristotle (384-322 BC) made one of the first references to deliberately eating clay, earth, or soil by humans for therapeutic and religious purposes. Later, Marco Polo described in his travels seeing Muslim pilgrims cure fevers by ingesting “pink earth.”
The ochres have also long been found in indigenous and aboriginal art, and in current day Namibia, the Himba tribe have used Otjize paste (bright red clay consisting of butterfat, red ochre, and sometimes herbs) for their characteristic hairstyles and makeup, as well as for skin protection and as a soap replacement. Otjize is sacred to the culture and ethnic identity, signifying the beauty of their hair and skin and a sense of oneness with their surroundings (the earth). There are also many instances of religious, folklore, or mythological references of creation of life or creation of humankind from clay.
Dermatologic uses
The most common uses of clay in dermatology are for treatment of acne and in spa or cosmeceutical preparations to purportedly draw out dirt, impurities, or toxins.
Clay minerals are most commonly formed from prolonged chemical weathering of silicate-bearing rocks. Clay can also be formed from hydrothermal or volcanic activity. Chemical weathering takes place mainly by acid hydrolysis resulting from low concentrations of carbonic acid, dissolved in rainwater or released by plant roots. Clays differ in composition and structure depending upon the source. Simplistically, clay is structured in two layers, organized in various shapes, with varying minerals and electrical charges. The electric charge of clay allows the adsorption of various minerals, water, heavy and radioactive metals, free radicals, and other potentially unwanted byproducts of metabolic activity. With antibacterial properties and adsorptive properties, clay is often used to dry out acne or oily skin and/or to improve the appearance of large pores.
Bentonite clay
Bentonite clay is one of the most common forms of clay used in topical skin products. Bentonite clay, formed after volcanic ash has weathered and aged in the presence of water, is named after a formation called Benton Shale in the western United States. Bentonite has a strong negative electromagnetic charge and when mixed with water it swells like a sponge and can absorb 40-50 times its weight.
There are several types of Bentonite clay, named from the dominant element found within: Sodium bentonite, calcium bentonite, aluminum bentonite, and potassium bentonite are the most common. Bentonite clay is most commonly found in off-white or green colors.
Kaolin and red clay
Typically white or nearly white to sometimes gray in color, kaolin clay is one of the other most common types of clay used in skin care. While the minerals of the kaolin group display a relatively small specific surface area, compared with those of other clay groups, they can still adsorb small molecules, proteins, bacteria, and viruses on the surface of their particles.
Red clay, also sometimes seen in skin care, takes on its color because of a higher content of iron oxides.
In a 2011 study, Valenti et al. evaluated the impact of daily application of clay and retinoic acid 0.025% on the skin of rats.After 7 days, skin where clay had been applied showed a significant increase in collagen fibers, compared with control skin, while areas where retinoic acid had been applied did not show a significant increase in collagen fibers, compared with control skin.2
A recently published study claims that pH and its interaction with the clay particle surface charge may neutralize and impact properties – including antibacterial properties – of clay and is more significant than previously thought.3 The authors emphasize the dangers of this possibility with unregulated marketing and unsubstantiated bioceutical claims of products that contain clay. Many clay-based skin care products on the market today include other ingredients such as acids (for example salicylic acid, lactic acid, and malic acid) that may potentially counteract this issue and help enhance the targeted efficacy of the product.
The types and characteristics of all types of clay go beyond the scope of this column, but as demonstrated throughout history, clay may have a role in medicinal and dermatologic care, the research of which is still ongoing and is important in our understanding of how this earthly compound can affect our bodies.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1: Moraes JDD et al. Int J Pharm. 2017 Dec 20;534(1-2):213-219. doi: 10.1016/j.ijpharm.2017.10.031.
2: Valenti DMZ et al. Clin Exp Dermatol. 2012 Mar;37(2):164-8. doi: 10.1111/j.1365-2230.2011.04216.x
3. Incledion A et al. Biomolecules. 2021 Jan 5;11(1):58. doi: 10.3390/biom11010058.
Natural clay from the earth and its minerals, imperative for survival of life on our planet, have been used for medicinal purposes for thousands of years. , and for some, the environmental and sustainability viewpoint that minerals will not harm the environment after disposal.
Clay minerals namely consist of silica, alumina, and/or magnesia, and sometimes varying degrees of iron, sodium, potassium, calcium, and water. Depending on the type of clay, as many as 75 trace minerals may be present.
Ochre
The first uses of ochre, or natural clay earth pigment, are thought to be by Homo erectus and Homo neanderthalensis who used ochre with water to soothe irritations, heal wounds, and clean skin. The theory is that they mimicked some animals who instinctively used clay/mud/minerals in this manner.
The first recorded use of medicinal clay is on Mesopotamian clay tablets, dating to about 2500 B.C. The ancient Egyptian physicians used clays as anti-inflammatory agents and antiseptics. Clay was also used as a preservative during mummification.
Throughout history, clay has been used for dermatologic purposes. Aristotle (384-322 BC) made one of the first references to deliberately eating clay, earth, or soil by humans for therapeutic and religious purposes. Later, Marco Polo described in his travels seeing Muslim pilgrims cure fevers by ingesting “pink earth.”
The ochres have also long been found in indigenous and aboriginal art, and in current day Namibia, the Himba tribe have used Otjize paste (bright red clay consisting of butterfat, red ochre, and sometimes herbs) for their characteristic hairstyles and makeup, as well as for skin protection and as a soap replacement. Otjize is sacred to the culture and ethnic identity, signifying the beauty of their hair and skin and a sense of oneness with their surroundings (the earth). There are also many instances of religious, folklore, or mythological references of creation of life or creation of humankind from clay.
Dermatologic uses
The most common uses of clay in dermatology are for treatment of acne and in spa or cosmeceutical preparations to purportedly draw out dirt, impurities, or toxins.
Clay minerals are most commonly formed from prolonged chemical weathering of silicate-bearing rocks. Clay can also be formed from hydrothermal or volcanic activity. Chemical weathering takes place mainly by acid hydrolysis resulting from low concentrations of carbonic acid, dissolved in rainwater or released by plant roots. Clays differ in composition and structure depending upon the source. Simplistically, clay is structured in two layers, organized in various shapes, with varying minerals and electrical charges. The electric charge of clay allows the adsorption of various minerals, water, heavy and radioactive metals, free radicals, and other potentially unwanted byproducts of metabolic activity. With antibacterial properties and adsorptive properties, clay is often used to dry out acne or oily skin and/or to improve the appearance of large pores.
Bentonite clay
Bentonite clay is one of the most common forms of clay used in topical skin products. Bentonite clay, formed after volcanic ash has weathered and aged in the presence of water, is named after a formation called Benton Shale in the western United States. Bentonite has a strong negative electromagnetic charge and when mixed with water it swells like a sponge and can absorb 40-50 times its weight.
There are several types of Bentonite clay, named from the dominant element found within: Sodium bentonite, calcium bentonite, aluminum bentonite, and potassium bentonite are the most common. Bentonite clay is most commonly found in off-white or green colors.
Kaolin and red clay
Typically white or nearly white to sometimes gray in color, kaolin clay is one of the other most common types of clay used in skin care. While the minerals of the kaolin group display a relatively small specific surface area, compared with those of other clay groups, they can still adsorb small molecules, proteins, bacteria, and viruses on the surface of their particles.
Red clay, also sometimes seen in skin care, takes on its color because of a higher content of iron oxides.
In a 2011 study, Valenti et al. evaluated the impact of daily application of clay and retinoic acid 0.025% on the skin of rats.After 7 days, skin where clay had been applied showed a significant increase in collagen fibers, compared with control skin, while areas where retinoic acid had been applied did not show a significant increase in collagen fibers, compared with control skin.2
A recently published study claims that pH and its interaction with the clay particle surface charge may neutralize and impact properties – including antibacterial properties – of clay and is more significant than previously thought.3 The authors emphasize the dangers of this possibility with unregulated marketing and unsubstantiated bioceutical claims of products that contain clay. Many clay-based skin care products on the market today include other ingredients such as acids (for example salicylic acid, lactic acid, and malic acid) that may potentially counteract this issue and help enhance the targeted efficacy of the product.
The types and characteristics of all types of clay go beyond the scope of this column, but as demonstrated throughout history, clay may have a role in medicinal and dermatologic care, the research of which is still ongoing and is important in our understanding of how this earthly compound can affect our bodies.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1: Moraes JDD et al. Int J Pharm. 2017 Dec 20;534(1-2):213-219. doi: 10.1016/j.ijpharm.2017.10.031.
2: Valenti DMZ et al. Clin Exp Dermatol. 2012 Mar;37(2):164-8. doi: 10.1111/j.1365-2230.2011.04216.x
3. Incledion A et al. Biomolecules. 2021 Jan 5;11(1):58. doi: 10.3390/biom11010058.
