Naissan O. Wesley, MD

 

The use of permanent cosmetics dates back thousands of years in history. Microblading, a technique for creating natural looking eyebrows using pigment, has reemerged in popularity in the 21st century, and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.

The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

Microblading – also known as eyebrow embroidery, micropigmentation, dermal implantation, microstroking, microfeathering, and 3-D eyebrows – is a permanent make-up technique, and like any tattoo, pigment/ink will fade over time. Compared with traditional tattoos that are done with a machine, microblading is performed manually using a disposable, single-use, sterile, handheld tool to deposit hair-like strokes of pigment into the dermis. Fading occurs faster with microblading than with traditional micropigmentation techniques that are performed with a machine. This is caused by pigment expulsion that occurs because of bleeding during the microblading procedure. Permanent make-up machines are able to rapidly deposit pigment into the dermis, which limits bleeding and pigment expulsion and therefore fades at a slower rate.

Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

As with any tattoo, complications can occur. Although extremely rare, pigment allergy, granulomatous reactions, exacerbation of underlying skin diseases (such as psoriasis or allergic contact dermatitis), and herpes simplex virus infections can occur. Also, if performed by someone with little or no knowledge about blood safety practices, infectious diseases can be contracted.

While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.

Fading and removal of microblading tattoos is controversial and remains a challenge. The process of removing a microblading treatment should be done by a highly trained provider. Scarring from the removal process is more likely when microblading has been performed than when removing a traditional tattoo, a result of how microblading tools deposit pigment through dragging motions in the skin.

The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.

Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.

In addition, dermatologists should be aware of this procedure and be cautious regarding exfoliating skin care regimens and in-office procedures that may affect the aesthetics or longevity of microblading eyebrows and for any cosmetic tattoo. Our patients inquiring about treatments should be counseled to find a highly trained, licensed micropigmentation artist licensed in their state, who also has proper safety certification (Bloodborne Pathogens training and First Aid Certification), insurance, and is performing the services in a licensed body art facility with sterile, single-use, disposable tools and pigments.

Like other cosmetic treatments, cheaper is never better.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected]. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.

 

The use of permanent cosmetics dates back thousands of years in history. Microblading, a technique for creating natural looking eyebrows using pigment, has reemerged in popularity in the 21st century, and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.

The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

Microblading – also known as eyebrow embroidery, micropigmentation, dermal implantation, microstroking, microfeathering, and 3-D eyebrows – is a permanent make-up technique, and like any tattoo, pigment/ink will fade over time. Compared with traditional tattoos that are done with a machine, microblading is performed manually using a disposable, single-use, sterile, handheld tool to deposit hair-like strokes of pigment into the dermis. Fading occurs faster with microblading than with traditional micropigmentation techniques that are performed with a machine. This is caused by pigment expulsion that occurs because of bleeding during the microblading procedure. Permanent make-up machines are able to rapidly deposit pigment into the dermis, which limits bleeding and pigment expulsion and therefore fades at a slower rate.

Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

As with any tattoo, complications can occur. Although extremely rare, pigment allergy, granulomatous reactions, exacerbation of underlying skin diseases (such as psoriasis or allergic contact dermatitis), and herpes simplex virus infections can occur. Also, if performed by someone with little or no knowledge about blood safety practices, infectious diseases can be contracted.

While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.

Fading and removal of microblading tattoos is controversial and remains a challenge. The process of removing a microblading treatment should be done by a highly trained provider. Scarring from the removal process is more likely when microblading has been performed than when removing a traditional tattoo, a result of how microblading tools deposit pigment through dragging motions in the skin.

The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.

Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.

In addition, dermatologists should be aware of this procedure and be cautious regarding exfoliating skin care regimens and in-office procedures that may affect the aesthetics or longevity of microblading eyebrows and for any cosmetic tattoo. Our patients inquiring about treatments should be counseled to find a highly trained, licensed micropigmentation artist licensed in their state, who also has proper safety certification (Bloodborne Pathogens training and First Aid Certification), insurance, and is performing the services in a licensed body art facility with sterile, single-use, disposable tools and pigments.

Like other cosmetic treatments, cheaper is never better.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected]. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.

 

The use of permanent cosmetics dates back thousands of years in history. Microblading, a technique for creating natural looking eyebrows using pigment, has reemerged in popularity in the 21st century, and has rapidly become one of the most popular cosmetic procedures in the United States. However, it has not completely replaced traditional eyebrow micropigmentation techniques: Many people may not be candidates for microblading because of how the pigment is manually deposited in the skin through tiny “tears” in the skin with this procedure.

The use of microblading has increased exponentially since 2015, as reflected by the millions of searches on popular social media sites. With the increase in the popularity and volume of tattoo artists performing these procedures, there has also been an increase in side effects and complications from microblading provided by poorly trained and unlicensed “artists,” a problem facilitated by the absence of adequate training requirements and/or regulatory oversight in many states.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

Microblading – also known as eyebrow embroidery, micropigmentation, dermal implantation, microstroking, microfeathering, and 3-D eyebrows – is a permanent make-up technique, and like any tattoo, pigment/ink will fade over time. Compared with traditional tattoos that are done with a machine, microblading is performed manually using a disposable, single-use, sterile, handheld tool to deposit hair-like strokes of pigment into the dermis. Fading occurs faster with microblading than with traditional micropigmentation techniques that are performed with a machine. This is caused by pigment expulsion that occurs because of bleeding during the microblading procedure. Permanent make-up machines are able to rapidly deposit pigment into the dermis, which limits bleeding and pigment expulsion and therefore fades at a slower rate.

Microblading is a revolutionary technique that can transform the lives of patients with hypotrichosis of the eyebrows, trichotillomania, eyebrow loss due to internal disease (such as thyroid disease), chemotherapy-induced eyebrow loss, or alopecia – or simply those seeking it for cosmetic improvement. The art of shaping the eyebrow depends on the natural growth of the brow (if any), facial symmetry, and meticulous measurement and mapping of the brow position based on facial landmarks and bone structure. The color of pigment selection is based on Fitzpatrick skin type and skin color undertones.

Lola Jonsson, Skin Care and Laser Physicians of Beverly Hills.

As with any tattoo, complications can occur. Although extremely rare, pigment allergy, granulomatous reactions, exacerbation of underlying skin diseases (such as psoriasis or allergic contact dermatitis), and herpes simplex virus infections can occur. Also, if performed by someone with little or no knowledge about blood safety practices, infectious diseases can be contracted.

While dermatologists usually do not perform microblading, we may see patients with these complications. Practitioners treating patients who have had eyebrow microblading should also be aware of how to prevent premature fading of the eyebrow tattoo pigment. Tattooed eyebrows should be covered with petroleum jelly prior to the use of alpha hydroxy acids, vitamin C, chemical peels, hydroquinone, or retinols because these preparations can fade the pigment rapidly even if applied far from the microblading site. Any UV exposure, heat (such as steam from a facial), LED light exposure, or radio frequency can fade the pigment and exacerbate postinflammatory hyperpigmentation. Patients who have a history of hypertrophic scarring or keloids or are using isotretinoin concurrently should avoid microblading entirely. Resurfacing lasers and intense pulsed-light lasers should be used with caution as these aesthetic procedures will cause fading of the eyebrow pigment even if applied at a considerable distance from the eyebrow. Microbladed eyebrows should be covered with 20% zinc oxide paste prior to the use of any intense pulsed-light or resurfacing lasers.

Fading and removal of microblading tattoos is controversial and remains a challenge. The process of removing a microblading treatment should be done by a highly trained provider. Scarring from the removal process is more likely when microblading has been performed than when removing a traditional tattoo, a result of how microblading tools deposit pigment through dragging motions in the skin.

The pigment used in eyebrow colors also may be composed of a mixture of iron oxide pigments, which should not be removed with traditional Q-switched lasers, with which not only is there potential for the pigment to darken but also postinflammatory hyper- or hypopigmentation to occur as well. Hairs can be singed, and the light absorbed by the pigment chromophore in the hair follicle can permanently damage the follicle, leading to hair loss in the area.

Despite the absolute precision and aggressive safety precautions needed for microblading, there are wide state-to-state variations in training and regulatory oversight. Infectious diseases, poor treatment outcomes, and unsterile conditions are just a few of the horrific consequences of unlicensed and untrained tattoo artists. Regulations should be imposed in every state to protect consumers and prevent serious medical complications related to microblading.

In addition, dermatologists should be aware of this procedure and be cautious regarding exfoliating skin care regimens and in-office procedures that may affect the aesthetics or longevity of microblading eyebrows and for any cosmetic tattoo. Our patients inquiring about treatments should be counseled to find a highly trained, licensed micropigmentation artist licensed in their state, who also has proper safety certification (Bloodborne Pathogens training and First Aid Certification), insurance, and is performing the services in a licensed body art facility with sterile, single-use, disposable tools and pigments.

Like other cosmetic treatments, cheaper is never better.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected]. This column was written with the help and professional expertise of Emily Joy, a cosmetic tattoo artist and the founder of Dollistic in McLean.

 

Collagen drinks and supplements have been getting a lot of buzz lately, from media advertisements and patients asking us about them. The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.

Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?

marekuliasz/iStock/Getty Images Plus

Hydrolyzed collagen is often derived from bovine bone and cartilage. Usually, the bone is crushed, ground, defatted, soaked in acid to remove the calcium, soaked again to break the collagen bonds, and then dehydrated, and typically ends up in the form of a powder. In this form, it is soluble in cold liquids and easily digestible. Hydrolyzed collagen taken orally has been shown to have antioxidant properties, antihypertensive and lipid-lowering activity, as well as reparative properties in damaged skin. Besides this, oral collagen supplementation has not been studied, and research in peer-reviewed journals has not yet been published demonstrating it’s benefit for skin and beauty (J Cosmet Dermatol. 2018 Feb;17[1]:20-6).

We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?

Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?

The source and type of collagen may also provide a difference in the effect it has, if any. Collagen itself has to come from an animal, a human, or a synthetic source. Animal sources are most commonly from bovine and porcine sources, although marine sources are increasingly being used. Bovine was once the most commonly used (as with Zyderm and Zyplast). Bovine collagen presents the risk of allergenicity and, less commonly, bovine spongiform encephalopathy. Plants do not contain collagen, but are purported to help boost ones own natural collagen by providing a source of vitamins and nutrients required for collagen production/remodeling. For example, carrots and sweet potatoes are rich in vitamin A, and vitamin A derivatives such as isotretinoin and tretinoin have been shown to provide collagen remodeling in improving acne, skin texture, and wrinkles. In a clinical trial, an oral drink containing soy, antioxidants (soy isoflavones, lycopene, Vitamins C and E), and a capsule of fish oil was shown to reduce facial-wrinkle depth in postmenopausal women thought to be caused by new collagen deposition (Int J Cosmet Sci. 2014 Feb;36[1]:22-31).

Type I collagen is found in tendon, ligaments, bone, and cornea. Types I, III, IV, and VII are the most predominate in skin (I in scar tissue, III in normal dermis, IV in basement membrane, and VII in dermal-epidermal junctions). With at least 28 types of collagen in the human body, perhaps the type of collagen being supplemented might play a role in where it is integrated and whether it benefits skin versus other tissues.

 

Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.

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.

 

Collagen drinks and supplements have been getting a lot of buzz lately, from media advertisements and patients asking us about them. The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.

Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?

marekuliasz/iStock/Getty Images Plus

Hydrolyzed collagen is often derived from bovine bone and cartilage. Usually, the bone is crushed, ground, defatted, soaked in acid to remove the calcium, soaked again to break the collagen bonds, and then dehydrated, and typically ends up in the form of a powder. In this form, it is soluble in cold liquids and easily digestible. Hydrolyzed collagen taken orally has been shown to have antioxidant properties, antihypertensive and lipid-lowering activity, as well as reparative properties in damaged skin. Besides this, oral collagen supplementation has not been studied, and research in peer-reviewed journals has not yet been published demonstrating it’s benefit for skin and beauty (J Cosmet Dermatol. 2018 Feb;17[1]:20-6).

We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?

Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?

The source and type of collagen may also provide a difference in the effect it has, if any. Collagen itself has to come from an animal, a human, or a synthetic source. Animal sources are most commonly from bovine and porcine sources, although marine sources are increasingly being used. Bovine was once the most commonly used (as with Zyderm and Zyplast). Bovine collagen presents the risk of allergenicity and, less commonly, bovine spongiform encephalopathy. Plants do not contain collagen, but are purported to help boost ones own natural collagen by providing a source of vitamins and nutrients required for collagen production/remodeling. For example, carrots and sweet potatoes are rich in vitamin A, and vitamin A derivatives such as isotretinoin and tretinoin have been shown to provide collagen remodeling in improving acne, skin texture, and wrinkles. In a clinical trial, an oral drink containing soy, antioxidants (soy isoflavones, lycopene, Vitamins C and E), and a capsule of fish oil was shown to reduce facial-wrinkle depth in postmenopausal women thought to be caused by new collagen deposition (Int J Cosmet Sci. 2014 Feb;36[1]:22-31).

Type I collagen is found in tendon, ligaments, bone, and cornea. Types I, III, IV, and VII are the most predominate in skin (I in scar tissue, III in normal dermis, IV in basement membrane, and VII in dermal-epidermal junctions). With at least 28 types of collagen in the human body, perhaps the type of collagen being supplemented might play a role in where it is integrated and whether it benefits skin versus other tissues.

 

Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.

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.

 

Collagen drinks and supplements have been getting a lot of buzz lately, from media advertisements and patients asking us about them. The question is, do they really do anything? Previously, most collagen supplements in the beauty industry came in the form of a topical cream or an injectable, with collagen being the main filler of choice before hyaluronic acid fillers became available. Today, collagen supplementation in the form of oral pills and drinks is rampant. These drinks and “vitamins” are purported to improve skin and provide a more youthful appearance, both from an immediate and preventative standpoint. Some of the drinks come from companies in Japan and beyond. According to market forecasts, the collagen supplement industry is anticipated to be worth $6.63 billion by 2025, up from $3.71 billion in 2016. An email advertisement this month from NewBeauty magazine claims one brand of collagen supplementation “with grape seed extract [as] an effective collagen drink for the skin.” Each 1.7 oz. bottle contains 13,000 mg of marine hydrolyzed collagen with six antiaging ingredients that – the ad claims – will help visibly transform your skin to a fuller, firmer, younger look in as soon as 21 days.

Diet absolutely plays a role in our overall health and skin appearance. But can these concentrated collagen drinks provide an increased benefit?

marekuliasz/iStock/Getty Images Plus

Hydrolyzed collagen is often derived from bovine bone and cartilage. Usually, the bone is crushed, ground, defatted, soaked in acid to remove the calcium, soaked again to break the collagen bonds, and then dehydrated, and typically ends up in the form of a powder. In this form, it is soluble in cold liquids and easily digestible. Hydrolyzed collagen taken orally has been shown to have antioxidant properties, antihypertensive and lipid-lowering activity, as well as reparative properties in damaged skin. Besides this, oral collagen supplementation has not been studied, and research in peer-reviewed journals has not yet been published demonstrating it’s benefit for skin and beauty (J Cosmet Dermatol. 2018 Feb;17[1]:20-6).

We know from prior experience with injecting collagen in the lips – namely from bovine (such as Zyderm and Zyplast) or human-derived (such as Cosmoderm and CosmoPlast) sources – that it provided beautiful and often natural-appearing results, which, however, did not last. If longevity is an issue with collagen injections, assuming proper absorption from the gastrointestinal tract and subsequent integration into skin, how long should we expect the results from drinking collagen to last in skin, if any? If it does work and is something that improves skin when used on a continuous basis, is there an endpoint at which the benefit is maximized or where an excess of collagen could be detrimental?

Collagen disorders are those where there is inflammation or deficiency in collagen. Could supplementation improve these diseases? Or could supplementation exacerbate or bring on these disorders if consumed in excess? In collagen vascular diseases, such as scleroderma, where apparent autoimmune inflammation of collagen occurs, would supplementation exacerbate the disease by bringing about more collagen to attack, or would it improve the condition by providing new collagen where there may be a defect? Would it help in conditions of collagen deficiency, such as osteogenesis imperfecta?

The source and type of collagen may also provide a difference in the effect it has, if any. Collagen itself has to come from an animal, a human, or a synthetic source. Animal sources are most commonly from bovine and porcine sources, although marine sources are increasingly being used. Bovine was once the most commonly used (as with Zyderm and Zyplast). Bovine collagen presents the risk of allergenicity and, less commonly, bovine spongiform encephalopathy. Plants do not contain collagen, but are purported to help boost ones own natural collagen by providing a source of vitamins and nutrients required for collagen production/remodeling. For example, carrots and sweet potatoes are rich in vitamin A, and vitamin A derivatives such as isotretinoin and tretinoin have been shown to provide collagen remodeling in improving acne, skin texture, and wrinkles. In a clinical trial, an oral drink containing soy, antioxidants (soy isoflavones, lycopene, Vitamins C and E), and a capsule of fish oil was shown to reduce facial-wrinkle depth in postmenopausal women thought to be caused by new collagen deposition (Int J Cosmet Sci. 2014 Feb;36[1]:22-31).

Type I collagen is found in tendon, ligaments, bone, and cornea. Types I, III, IV, and VII are the most predominate in skin (I in scar tissue, III in normal dermis, IV in basement membrane, and VII in dermal-epidermal junctions). With at least 28 types of collagen in the human body, perhaps the type of collagen being supplemented might play a role in where it is integrated and whether it benefits skin versus other tissues.

 

Many questions about collagen drinks and supplementation remain to be answered. Photoprotection from an early age and a healthy diet that supports production of our bodies’ own natural collagen are the best measures for skin health. With the surplus of collagen drinks and supplements now on the market, objective studies should be conducted and are warranted to answer these question for ourselves and our patients.

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.

 

Formerly known as A-101, Eskata is a novel topical treatment for seborrheic keratoses (SKs) that was approved by the Food and Drug Administration in December 2017. It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.

James Heilman, MD/Wikimedia Commons/CC BY-SA 3.0

While the mechanism of action of Eskata is unknown, highly reactive oxygen species likely created from application of this concentration of hydrogen peroxide may lead to direct oxidative damage to SK cells. The oxidative damage created can induce local protein, lipid, and membrane peroxidation, and ultimately, necrotic and apoptotic cell death of the SK cells.

Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.

Like other treatments for SKs, these reactions may begin within 10 minutes, and it may take 1-2 weeks for the lesion to resolve.

In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).

Current therapies for SKs include cryotherapy, electrodessication, curettage, shave biopsy/removal, and laser therapy. As SKs affect at least 83 million Americans and are bothersome to patients because of cosmetic disfigurement, irritation, unnecessary diagnostic biopsies, or annoyance, this novel therapy provides a noninvasive treatment option with the potential to supersede all prior therapies with less pain and risk of pigmentary alteration and scarring from the procedure. It is expected to be commercially available in the spring of 2018.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at [email protected].

 

Formerly known as A-101, Eskata is a novel topical treatment for seborrheic keratoses (SKs) that was approved by the Food and Drug Administration in December 2017. It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.

James Heilman, MD/Wikimedia Commons/CC BY-SA 3.0

While the mechanism of action of Eskata is unknown, highly reactive oxygen species likely created from application of this concentration of hydrogen peroxide may lead to direct oxidative damage to SK cells. The oxidative damage created can induce local protein, lipid, and membrane peroxidation, and ultimately, necrotic and apoptotic cell death of the SK cells.

Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.

Like other treatments for SKs, these reactions may begin within 10 minutes, and it may take 1-2 weeks for the lesion to resolve.

In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).

Current therapies for SKs include cryotherapy, electrodessication, curettage, shave biopsy/removal, and laser therapy. As SKs affect at least 83 million Americans and are bothersome to patients because of cosmetic disfigurement, irritation, unnecessary diagnostic biopsies, or annoyance, this novel therapy provides a noninvasive treatment option with the potential to supersede all prior therapies with less pain and risk of pigmentary alteration and scarring from the procedure. It is expected to be commercially available in the spring of 2018.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at [email protected].

 

Formerly known as A-101, Eskata is a novel topical treatment for seborrheic keratoses (SKs) that was approved by the Food and Drug Administration in December 2017. It is a 40% hydrogen peroxide topical solution that is applied to raised SKs as an in-office procedure. As previously reported, SKs are composed of hyperadherent senescent cells that are arrested in the G1 phase of the cell cycle. They exhibit decreased apoptotic cell death, compared with normal skin.

James Heilman, MD/Wikimedia Commons/CC BY-SA 3.0

While the mechanism of action of Eskata is unknown, highly reactive oxygen species likely created from application of this concentration of hydrogen peroxide may lead to direct oxidative damage to SK cells. The oxidative damage created can induce local protein, lipid, and membrane peroxidation, and ultimately, necrotic and apoptotic cell death of the SK cells.

Two double-blind vehicle-controlled studies demonstrated that more patients were clear or near clear of SKs after use of the 40% concentration solution than those in the vehicle group, according to the prescribing information. In the studies, patients with four raised SKs of the face, trunk or extremities were treated with Eskata at baseline and 3 weeks later, if necessary, or a vehicle. None of those in the vehicle group were cleared at follow-up (day 106), compared with 4% and 8% of those treated with Eskata, and at least three of the four lesions treated with Eskata had cleared in 13% and 23% at follow-up. Local skin reactions were mostly mild and transient, the most common being itching, stinging, crusting, swelling, redness, and scaling at the application site.

Like other treatments for SKs, these reactions may begin within 10 minutes, and it may take 1-2 weeks for the lesion to resolve.

In the clinical studies, the solution was applied up to two times, on day 0 and again 3 weeks later on day 22. The lesion should first be cleansed with alcohol, and appropriate measures should be taken to ensure Eskata does not come in contact with the eyes. Nitrile or vinyl examination gloves should be used for application. Eskata is applied to the SKs with a pen-like applicator. The solution is applied uniformly in a circular motion with excess and the surrounding area patted dry with an absorbent wipe. Cotton gauze, tips, paper towels, or tissue should not be used as organic compounds can react with high concentrations of hydrogen peroxide. In a treatment session, one lesion may be treated up to four times, 1 minute apart. The applicator is used only once and may be discarded after lesions are treated. The packages may be stored at controlled room temperature (68° F to 77° F).

Current therapies for SKs include cryotherapy, electrodessication, curettage, shave biopsy/removal, and laser therapy. As SKs affect at least 83 million Americans and are bothersome to patients because of cosmetic disfigurement, irritation, unnecessary diagnostic biopsies, or annoyance, this novel therapy provides a noninvasive treatment option with the potential to supersede all prior therapies with less pain and risk of pigmentary alteration and scarring from the procedure. It is expected to be commercially available in the spring of 2018.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, the manufacturer of Eskata. Dr. Talakoub had no related disclosures. Write to them at [email protected].

 

The rise of noninvasive procedures has shifted the aesthetic culture. Patients now are asking for less invasive, less painful, less expensive procedures with short recovery times. Thread-lifts are one of the newest approaches to nonsurgical facial tightening. However, are they of value? Where, and for whom?

Conceptually, the thread-lift is the suspension of ptotic facial soft tissue via a thread subcutaneously inserted in the skin. It is an easy, fast, in-office procedure in which a cone attachment or barbed or nonbarbed suture thread is inserted via a cannula into the skin through a very small incision. The thread is essentially “hooked” to the skin and, with a minimal amount of tightening, the skin is lifted and the suture is cut at the insertion point. The sutures dissolve and, over time, produce scar tissue.

The thread-lifts initially came onto the market in the late 1990s but were difficult to use. The nonabsorbable threads had to be anchored into the scalp, temple, and brow region. The anchoring knots were carefully tied and were permanent. The newest technology threads – NovaThreads and the Silhouette Instalift – have recently received Food and Drug Administration clearance and grown in popularity because of their “lunchtime” appeal and their ease of use. Primarily marketed for the neck, jowls, and lower face, these threads – available in various sizes, lengths, and diameters – can be used almost anywhere. The sutures dissolve over time and do not need any anchoring, making it a very simple in-office procedure.

Side effects include mild procedural pain, edema, erythema, bruising, and rarely, suture granuloma formation; and they may need to be replaced. If not done properly, buckling of the skin can occur and superficially placed sutures can be visible.

Similar to fillers that provide a “liquid face-lift,” the down time is minimal. Common side effects include bruising, and patients should refrain from heavy exercise and opening their mouth wide with chewing for 5-7 days (such as eating a large apple). Soreness, particularly in or near the hairline or jaw line, can occur and can last up to 2 weeks. Dimpling in the skin can occur and usually resolves on its own; however, if threads are placed incorrectly, dimpling can cause some disfigurement.

Results can vary based on the tissue laxity, and the type, amount, and location of the threads used. While results have been reported to last 18 months to 2 years, the procedure is not a replacement for fillers. Facial aging is caused by a combination of skeletal, soft tissue, and skin changes that lead to soft tissue laxity and volume loss. Fillers are essential in restoring lost volume in the aging face and are particularly helpful in combination with tissue tightening lasers, face-lifts and the thread-lift procedures. Fillers used in combination with thread-lifts also increase the longevity of the thread-lift because of additional collagen stimulation.

As the procedure is not indicated for severe laxity, thread-lifts also do not replace the traditional face-lift. Tissue is not released from its underlying attachments, and skin contraction and gravitational pull limit its extent of improvement and its longevity.

Long-term success of the thread-lift procedure for facial rejuvenation was evaluated in a retrospective review of 33 patients who underwent the traditional thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, mid-face, jowl, and neck published in 2009.¹ The study compared results in 10 patients who had a thread-lift alone, 23 who had thread-lifts combined with other procedures, and controls, who were 10 ten patients who had non–thread-lift rejuvenation procedures, which included lipotransfer, chemical peels, and rhytidectomies. Independent, blinded, board-certified facial plastic surgeons evaluated pre- and postoperative photos. Patients were followed-up for a mean of 21 months.

At 1 month, aesthetic improvements were observed in all treatment groups. Measurable results through the end of the study period were seen in all the patient groups, with the exception of the group of patients who had the thread-lift procedure alone. Aesthetic improvements observed in the control group were significantly better than were the improvements in the thread-lift only group. In addition, aesthetic improvement scores among those who had the thread-lift plus other procedures were significantly better than were the scores among those who had the thread-lift only. The authors concluded that the thread-lift procedure resulted in only short-term improvements, because of the edema and inflammation related to the procedure. They also concluded that thread-lifts were not effective because they did not produce any volumetric change and only superficially repositioned the soft tissues without addressing excess skin.

While thread-lifts are a beneficial addition to our armamentarium of noninvasive aesthetic procedures, they have better outcomes and higher patient satisfaction when used in combination with fillers, radiofrequency, and fractional lasers and neuromodulators.

Reference

1. Abraham RF et al. Arch Facial Plast Surg. 2009 May-Jun;11(3):178-83.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

 

The rise of noninvasive procedures has shifted the aesthetic culture. Patients now are asking for less invasive, less painful, less expensive procedures with short recovery times. Thread-lifts are one of the newest approaches to nonsurgical facial tightening. However, are they of value? Where, and for whom?

Conceptually, the thread-lift is the suspension of ptotic facial soft tissue via a thread subcutaneously inserted in the skin. It is an easy, fast, in-office procedure in which a cone attachment or barbed or nonbarbed suture thread is inserted via a cannula into the skin through a very small incision. The thread is essentially “hooked” to the skin and, with a minimal amount of tightening, the skin is lifted and the suture is cut at the insertion point. The sutures dissolve and, over time, produce scar tissue.

The thread-lifts initially came onto the market in the late 1990s but were difficult to use. The nonabsorbable threads had to be anchored into the scalp, temple, and brow region. The anchoring knots were carefully tied and were permanent. The newest technology threads – NovaThreads and the Silhouette Instalift – have recently received Food and Drug Administration clearance and grown in popularity because of their “lunchtime” appeal and their ease of use. Primarily marketed for the neck, jowls, and lower face, these threads – available in various sizes, lengths, and diameters – can be used almost anywhere. The sutures dissolve over time and do not need any anchoring, making it a very simple in-office procedure.

Side effects include mild procedural pain, edema, erythema, bruising, and rarely, suture granuloma formation; and they may need to be replaced. If not done properly, buckling of the skin can occur and superficially placed sutures can be visible.

Similar to fillers that provide a “liquid face-lift,” the down time is minimal. Common side effects include bruising, and patients should refrain from heavy exercise and opening their mouth wide with chewing for 5-7 days (such as eating a large apple). Soreness, particularly in or near the hairline or jaw line, can occur and can last up to 2 weeks. Dimpling in the skin can occur and usually resolves on its own; however, if threads are placed incorrectly, dimpling can cause some disfigurement.

Results can vary based on the tissue laxity, and the type, amount, and location of the threads used. While results have been reported to last 18 months to 2 years, the procedure is not a replacement for fillers. Facial aging is caused by a combination of skeletal, soft tissue, and skin changes that lead to soft tissue laxity and volume loss. Fillers are essential in restoring lost volume in the aging face and are particularly helpful in combination with tissue tightening lasers, face-lifts and the thread-lift procedures. Fillers used in combination with thread-lifts also increase the longevity of the thread-lift because of additional collagen stimulation.

As the procedure is not indicated for severe laxity, thread-lifts also do not replace the traditional face-lift. Tissue is not released from its underlying attachments, and skin contraction and gravitational pull limit its extent of improvement and its longevity.

Long-term success of the thread-lift procedure for facial rejuvenation was evaluated in a retrospective review of 33 patients who underwent the traditional thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, mid-face, jowl, and neck published in 2009.¹ The study compared results in 10 patients who had a thread-lift alone, 23 who had thread-lifts combined with other procedures, and controls, who were 10 ten patients who had non–thread-lift rejuvenation procedures, which included lipotransfer, chemical peels, and rhytidectomies. Independent, blinded, board-certified facial plastic surgeons evaluated pre- and postoperative photos. Patients were followed-up for a mean of 21 months.

At 1 month, aesthetic improvements were observed in all treatment groups. Measurable results through the end of the study period were seen in all the patient groups, with the exception of the group of patients who had the thread-lift procedure alone. Aesthetic improvements observed in the control group were significantly better than were the improvements in the thread-lift only group. In addition, aesthetic improvement scores among those who had the thread-lift plus other procedures were significantly better than were the scores among those who had the thread-lift only. The authors concluded that the thread-lift procedure resulted in only short-term improvements, because of the edema and inflammation related to the procedure. They also concluded that thread-lifts were not effective because they did not produce any volumetric change and only superficially repositioned the soft tissues without addressing excess skin.

While thread-lifts are a beneficial addition to our armamentarium of noninvasive aesthetic procedures, they have better outcomes and higher patient satisfaction when used in combination with fillers, radiofrequency, and fractional lasers and neuromodulators.

Reference

1. Abraham RF et al. Arch Facial Plast Surg. 2009 May-Jun;11(3):178-83.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

 

The rise of noninvasive procedures has shifted the aesthetic culture. Patients now are asking for less invasive, less painful, less expensive procedures with short recovery times. Thread-lifts are one of the newest approaches to nonsurgical facial tightening. However, are they of value? Where, and for whom?

Conceptually, the thread-lift is the suspension of ptotic facial soft tissue via a thread subcutaneously inserted in the skin. It is an easy, fast, in-office procedure in which a cone attachment or barbed or nonbarbed suture thread is inserted via a cannula into the skin through a very small incision. The thread is essentially “hooked” to the skin and, with a minimal amount of tightening, the skin is lifted and the suture is cut at the insertion point. The sutures dissolve and, over time, produce scar tissue.

The thread-lifts initially came onto the market in the late 1990s but were difficult to use. The nonabsorbable threads had to be anchored into the scalp, temple, and brow region. The anchoring knots were carefully tied and were permanent. The newest technology threads – NovaThreads and the Silhouette Instalift – have recently received Food and Drug Administration clearance and grown in popularity because of their “lunchtime” appeal and their ease of use. Primarily marketed for the neck, jowls, and lower face, these threads – available in various sizes, lengths, and diameters – can be used almost anywhere. The sutures dissolve over time and do not need any anchoring, making it a very simple in-office procedure.

Side effects include mild procedural pain, edema, erythema, bruising, and rarely, suture granuloma formation; and they may need to be replaced. If not done properly, buckling of the skin can occur and superficially placed sutures can be visible.

Similar to fillers that provide a “liquid face-lift,” the down time is minimal. Common side effects include bruising, and patients should refrain from heavy exercise and opening their mouth wide with chewing for 5-7 days (such as eating a large apple). Soreness, particularly in or near the hairline or jaw line, can occur and can last up to 2 weeks. Dimpling in the skin can occur and usually resolves on its own; however, if threads are placed incorrectly, dimpling can cause some disfigurement.

Results can vary based on the tissue laxity, and the type, amount, and location of the threads used. While results have been reported to last 18 months to 2 years, the procedure is not a replacement for fillers. Facial aging is caused by a combination of skeletal, soft tissue, and skin changes that lead to soft tissue laxity and volume loss. Fillers are essential in restoring lost volume in the aging face and are particularly helpful in combination with tissue tightening lasers, face-lifts and the thread-lift procedures. Fillers used in combination with thread-lifts also increase the longevity of the thread-lift because of additional collagen stimulation.

As the procedure is not indicated for severe laxity, thread-lifts also do not replace the traditional face-lift. Tissue is not released from its underlying attachments, and skin contraction and gravitational pull limit its extent of improvement and its longevity.

Long-term success of the thread-lift procedure for facial rejuvenation was evaluated in a retrospective review of 33 patients who underwent the traditional thread-lift procedure alone or in combination with other facial rejuvenation procedures to the brow, mid-face, jowl, and neck published in 2009.¹ The study compared results in 10 patients who had a thread-lift alone, 23 who had thread-lifts combined with other procedures, and controls, who were 10 ten patients who had non–thread-lift rejuvenation procedures, which included lipotransfer, chemical peels, and rhytidectomies. Independent, blinded, board-certified facial plastic surgeons evaluated pre- and postoperative photos. Patients were followed-up for a mean of 21 months.

At 1 month, aesthetic improvements were observed in all treatment groups. Measurable results through the end of the study period were seen in all the patient groups, with the exception of the group of patients who had the thread-lift procedure alone. Aesthetic improvements observed in the control group were significantly better than were the improvements in the thread-lift only group. In addition, aesthetic improvement scores among those who had the thread-lift plus other procedures were significantly better than were the scores among those who had the thread-lift only. The authors concluded that the thread-lift procedure resulted in only short-term improvements, because of the edema and inflammation related to the procedure. They also concluded that thread-lifts were not effective because they did not produce any volumetric change and only superficially repositioned the soft tissues without addressing excess skin.

While thread-lifts are a beneficial addition to our armamentarium of noninvasive aesthetic procedures, they have better outcomes and higher patient satisfaction when used in combination with fillers, radiofrequency, and fractional lasers and neuromodulators.

Reference

1. Abraham RF et al. Arch Facial Plast Surg. 2009 May-Jun;11(3):178-83.
 

Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

 

One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”

The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.¹

We all know what SKs are. But what exactly ARE SKs? Studies in recent years have shown both genetic and viral etiologies for some SKs, but not all. FGFR3 and PIK3CA gene mutations have been found with the highest frequency in SKs, particularly familial SKs. More recently, activating mutations of EGFR, HRAS, and KRAS have also been found to contribute to the pathogenesis of SK, although at a lower frequency than the former.²

Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.³

Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO₂ laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.⁴

SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].

References:

1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf

2: Am J Dermatopathol. 2014 Aug;36(8):635-42.

3: Indian J Dermatol. 2013 Jul;58(4):326.

4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..

 

One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”

The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.¹

We all know what SKs are. But what exactly ARE SKs? Studies in recent years have shown both genetic and viral etiologies for some SKs, but not all. FGFR3 and PIK3CA gene mutations have been found with the highest frequency in SKs, particularly familial SKs. More recently, activating mutations of EGFR, HRAS, and KRAS have also been found to contribute to the pathogenesis of SK, although at a lower frequency than the former.²

Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.³

Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO₂ laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.⁴

SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].

References:

1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf

2: Am J Dermatopathol. 2014 Aug;36(8):635-42.

3: Indian J Dermatol. 2013 Jul;58(4):326.

4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..

 

One of the most common reasons for visits to the dermatologist is a brown or flesh-colored lesion on the face or body that is concerning to the patient either because it’s changing; it’s scabbing or bleeding; it feels rough on the surface, and they can’t stand touching it – or because the patient just thinks they’re plain unsightly. After assessing and ruling out a malignant skin cancer or precancerous lesion clinically, the good news is that, in most cases, these turn out to be seborrheic keratoses (SK), benign growths. Patients are often reassured and relieved when we tell them we nickname SKs “barnacles that come with wisdom.” But then they often ask, “can I get rid of them?”

The answer is yes. There are many ways to rid people of these pesky lesions, but the reality is that, even with coding and documentation of an irritated SK, they are rarely covered by insurance. This leaves patients with the choice of whether to pay out of pocket for a cosmetic procedure and puts the dermatologist in a position of either charging the patient for a cosmetic procedure or treating to make the patient happy and not getting compensated for their services. For the cosmetic dermatologist, discussing cosmetic procedures with patients is an easy transition, but for the dermatologist who does not regularly practice cosmetic or fee-for-service dermatology – the majority of dermatologists in the United States – this can put them in an awkward position. According to a 2013 workforce survey, 20% of the dermatology market is cosmetic, while 80% is medical, surgical, and dermatopathology.¹

We all know what SKs are. But what exactly ARE SKs? Studies in recent years have shown both genetic and viral etiologies for some SKs, but not all. FGFR3 and PIK3CA gene mutations have been found with the highest frequency in SKs, particularly familial SKs. More recently, activating mutations of EGFR, HRAS, and KRAS have also been found to contribute to the pathogenesis of SK, although at a lower frequency than the former.²

Given the clinically verrucous nature of SKs, a viral etiology, particularly human papilloma virus (HPV), has often been sought. HPV subtypes have been seen in genital “SKs” and HPV-23 has been associated with stucco keratoses, which often resemble the SK family and are found on the legs of aging patients. However, multiple reports have refuted the presence of HPV in nongenital SK lesions.³

Until a potential gene therapy is available, current treatment options for patients who want to have their SKs treated include cryotherapy, electrodesiccation, curettage, or laser therapy with a KTP (potassium titanyl phosphate) laser or an ablative laser, such as a CO₂ laser. Cryotherapy, curettage, and electrodesiccation, while effective, run a risk of dyspigmentation, especially hypopigmentation in Fitzpatrick Skin Types III-VI. KTP and ablative lasers can be effective, but are often less cost-effective methods to achieve similar results as cryotherapy or electrodesiccation. Clinical trial data have been published on a topical hydrogen peroxide–based solution, A-101, which is not currently approved by the Food and Drug Administration. In a recently published study, 68% of patients were clear or near clear of SKs on the face with the 40% A-101 solution after up to two treatments.⁴

SKs are a part of a cosmetic dermatology practice that arises on a daily basis and are often a concern for patients. Discussion of their management, coverage, and treatment options will resonate with every practicing dermatologist.
 

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Dr. Wesley has served on an advisory board panel for Aclaris, which is developing A-101. Write to them at [email protected].

References:

1: www.harriswilliams.com/system/files/industry_update/dermatology_market_overview.pdf

2: Am J Dermatopathol. 2014 Aug;36(8):635-42.

3: Indian J Dermatol. 2013 Jul;58(4):326.

4. Dermatol Surg. 2017 Sep 4. doi: 10.1097/DSS.0000000000001302..

As a follow-up to our previous column on the effects of climate change on the skin (Dermatology News, June 2016, p. 28), this month’s column will focus on a study recently published in Clinical Infectious Diseases that explores warmer weather as a possible risk factor for cellulitis.¹ As the summer continues with sweltering weather, humidity, and the recent spate of hurricanes in North America, it’s interesting to think about how the climate affects our patients and puts them at risk.

rottadana/Thinkstock

Analyzing hospital discharge data from a national inpatient health care database (the National Inpatient Sample) from 1998 to 2011 of more than 108 million hospital admissions (of which 1.3% were for cellulitis), the investigators found that the odds of a hospital admission for cellulitis increased with higher temperatures, with a dose-response pattern. Their analysis included diagnosis codes for cellulitis, abscess of the fingers and toes, and other cellulitis/abscess, and they used national climate data to estimate the average monthly temperature for different regions.

The odds of cellulitis admissions increased by roughly 3.55% for each 5° F increment in temperature. For example, the odds of being admitted to the hospital with cellulitis were 66.3% greater during a hot July with an average temperature above 90°F than during a cold February in some regions where the monthly temperature averaged below 40°F. Several comorbidities associated with infection risk were also strongly associated with a higher odds of a cellulitis admission in this study: For example, for patients with diabetes, the odds were 146% higher, and for patients labeled as obese, the odds were 122% higher.

Since bacteria and fungi – especially gram-positive organisms, such as staphylococcus and streptococcus, that most commonly cause skin and soft-tissue infections – often thrive in warm moist environments, it’s not surprising that warmer weather is playing a role in an increased prevalence of infectious diseases during the warmer months.

Much attention has been given to global warming and climate change over the past several years. The results of this study demonstrate that, if temperatures consistently increase, the odds of cellulitis also may increase in regions exposed to warmer temperatures.
 

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.

Reference

1. Clin Infect Dis. 2017 Jul 31. doi: 10.1093/cid/cix487.


 

As a follow-up to our previous column on the effects of climate change on the skin (Dermatology News, June 2016, p. 28), this month’s column will focus on a study recently published in Clinical Infectious Diseases that explores warmer weather as a possible risk factor for cellulitis.¹ As the summer continues with sweltering weather, humidity, and the recent spate of hurricanes in North America, it’s interesting to think about how the climate affects our patients and puts them at risk.

rottadana/Thinkstock

Analyzing hospital discharge data from a national inpatient health care database (the National Inpatient Sample) from 1998 to 2011 of more than 108 million hospital admissions (of which 1.3% were for cellulitis), the investigators found that the odds of a hospital admission for cellulitis increased with higher temperatures, with a dose-response pattern. Their analysis included diagnosis codes for cellulitis, abscess of the fingers and toes, and other cellulitis/abscess, and they used national climate data to estimate the average monthly temperature for different regions.

The odds of cellulitis admissions increased by roughly 3.55% for each 5° F increment in temperature. For example, the odds of being admitted to the hospital with cellulitis were 66.3% greater during a hot July with an average temperature above 90°F than during a cold February in some regions where the monthly temperature averaged below 40°F. Several comorbidities associated with infection risk were also strongly associated with a higher odds of a cellulitis admission in this study: For example, for patients with diabetes, the odds were 146% higher, and for patients labeled as obese, the odds were 122% higher.

Since bacteria and fungi – especially gram-positive organisms, such as staphylococcus and streptococcus, that most commonly cause skin and soft-tissue infections – often thrive in warm moist environments, it’s not surprising that warmer weather is playing a role in an increased prevalence of infectious diseases during the warmer months.

Much attention has been given to global warming and climate change over the past several years. The results of this study demonstrate that, if temperatures consistently increase, the odds of cellulitis also may increase in regions exposed to warmer temperatures.
 

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.

Reference

1. Clin Infect Dis. 2017 Jul 31. doi: 10.1093/cid/cix487.


 

As a follow-up to our previous column on the effects of climate change on the skin (Dermatology News, June 2016, p. 28), this month’s column will focus on a study recently published in Clinical Infectious Diseases that explores warmer weather as a possible risk factor for cellulitis.¹ As the summer continues with sweltering weather, humidity, and the recent spate of hurricanes in North America, it’s interesting to think about how the climate affects our patients and puts them at risk.

rottadana/Thinkstock

Analyzing hospital discharge data from a national inpatient health care database (the National Inpatient Sample) from 1998 to 2011 of more than 108 million hospital admissions (of which 1.3% were for cellulitis), the investigators found that the odds of a hospital admission for cellulitis increased with higher temperatures, with a dose-response pattern. Their analysis included diagnosis codes for cellulitis, abscess of the fingers and toes, and other cellulitis/abscess, and they used national climate data to estimate the average monthly temperature for different regions.

The odds of cellulitis admissions increased by roughly 3.55% for each 5° F increment in temperature. For example, the odds of being admitted to the hospital with cellulitis were 66.3% greater during a hot July with an average temperature above 90°F than during a cold February in some regions where the monthly temperature averaged below 40°F. Several comorbidities associated with infection risk were also strongly associated with a higher odds of a cellulitis admission in this study: For example, for patients with diabetes, the odds were 146% higher, and for patients labeled as obese, the odds were 122% higher.

Since bacteria and fungi – especially gram-positive organisms, such as staphylococcus and streptococcus, that most commonly cause skin and soft-tissue infections – often thrive in warm moist environments, it’s not surprising that warmer weather is playing a role in an increased prevalence of infectious diseases during the warmer months.

Much attention has been given to global warming and climate change over the past several years. The results of this study demonstrate that, if temperatures consistently increase, the odds of cellulitis also may increase in regions exposed to warmer temperatures.
 

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.

Reference

1. Clin Infect Dis. 2017 Jul 31. doi: 10.1093/cid/cix487.


 

In a large country of only 3 million people (where wild horses outnumber people), with an estimated 2 million who live in the capital and 1 million who live a traditional nomadic lifestyle, traditional skin care and beauty practices can still be found.

In the capital city of Ulaanbaatar, women practice many of the same beauty regimens as those of women in other parts of mainstream Asia, with access to department store beauty counters and shopping malls found in major cities throughout the world. With the influx of movies and media into Mongolia from South Korea in the late 1990s, South Korean beauty regimens and standards have weaved their way into the urban culture. However, in rural Mongolia, where a nomadic way of life still predominates, certain beauty and cultural practices remain intact without the influence of mainstream culture.

While lucky enough to travel to rural Mongolia on a medical volunteer trip this summer, I was able to witness and inquire about some of these practices. I was extremely fortunate to meet and befriend a Mongolian woman, Tuvdendorj Dulguun, who shared some of these skin care secrets with me.

Homemade yogurt, a staple in rural Mongolia, is used on the face to help brighten the skin. In rural Mongolia, the yogurt is made and eaten fresh, thus lasts for 1-2 days if not refrigerated. The yogurt comes from cows and goats (rarely from other animals) that graze on open land without pesticides and are not fed hormones and grains. My personal diet doesn’t consist of much dairy, but I can say firsthand that in my opinion, it is delicious there. Yogurt is also applied to the skin to treat acne, but for acne the yogurt is fermented more than usual, so there is more acid to reduce the skin inflammation. (Lactic acid is typically what is found in fermented yogurt.)

Another secret is the use of sheep tail fat on the skin. A well fed sheep collects and stores a large amount of fat in the lower back and tail as an energy reserve – easily recognizable as a “fat bottom” on the animal. A mutton (older sheep only), when consumed, is typically prepared for special occasions, such as the new year’s festival “Tsagaan Sar” or a wedding. Sheep tail fat is thought to have more collagen and provide more moisturization than other beauty products, especially in the sometimes harsh, arid climate of Mongolia. This tradition is fading, but Tuvdendorj’s aunt still uses it and has beautiful skin. The fat in the sheep’s tail is full of nutrients, and is what’s used for human skin. Healthy fats have omega-3 fatty acids, which are anti-inflammatory, and contain essential fatty acids plus fat soluble vitamins – A, D, E, and K – which can be helpful for skin. Grass fed-animals tend to have more omega-3 fatty acids, whereas grain-fed animals tend to have more omega-6 than omega-3 fatty acids.

Headdresses, traditional clothing, and adornments are seen in traditional Mongolia, particularly during the Naadam festival. With naturally high cheek bones and oval eyes that have epicanthic folds, many Mongolian women have distinct features. Long black braided hair is seen as an adornment during festivals. In rural Mongolia, it is not uncommon to see rosy red cheeks, flushed with telangiectasias due to sun, wind, and snow. In the capital city, the distinctive telangiectatic cheeks are not seen as frequently; instead, many women wear eyeliner to highlight their oval eyes. With my mother’s side of the family being direct descendants of Mongolia to the Middle East, I found these beauty practices to be fascinating and they hold a special place in my heart.
 

Dr. Wesley and Dr. Talakoub are co-contributors 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.

Resource:

1. J Altern Complement Med. 2015 Jul;21(7):380-5.

In a large country of only 3 million people (where wild horses outnumber people), with an estimated 2 million who live in the capital and 1 million who live a traditional nomadic lifestyle, traditional skin care and beauty practices can still be found.

In the capital city of Ulaanbaatar, women practice many of the same beauty regimens as those of women in other parts of mainstream Asia, with access to department store beauty counters and shopping malls found in major cities throughout the world. With the influx of movies and media into Mongolia from South Korea in the late 1990s, South Korean beauty regimens and standards have weaved their way into the urban culture. However, in rural Mongolia, where a nomadic way of life still predominates, certain beauty and cultural practices remain intact without the influence of mainstream culture.

While lucky enough to travel to rural Mongolia on a medical volunteer trip this summer, I was able to witness and inquire about some of these practices. I was extremely fortunate to meet and befriend a Mongolian woman, Tuvdendorj Dulguun, who shared some of these skin care secrets with me.

Homemade yogurt, a staple in rural Mongolia, is used on the face to help brighten the skin. In rural Mongolia, the yogurt is made and eaten fresh, thus lasts for 1-2 days if not refrigerated. The yogurt comes from cows and goats (rarely from other animals) that graze on open land without pesticides and are not fed hormones and grains. My personal diet doesn’t consist of much dairy, but I can say firsthand that in my opinion, it is delicious there. Yogurt is also applied to the skin to treat acne, but for acne the yogurt is fermented more than usual, so there is more acid to reduce the skin inflammation. (Lactic acid is typically what is found in fermented yogurt.)

Another secret is the use of sheep tail fat on the skin. A well fed sheep collects and stores a large amount of fat in the lower back and tail as an energy reserve – easily recognizable as a “fat bottom” on the animal. A mutton (older sheep only), when consumed, is typically prepared for special occasions, such as the new year’s festival “Tsagaan Sar” or a wedding. Sheep tail fat is thought to have more collagen and provide more moisturization than other beauty products, especially in the sometimes harsh, arid climate of Mongolia. This tradition is fading, but Tuvdendorj’s aunt still uses it and has beautiful skin. The fat in the sheep’s tail is full of nutrients, and is what’s used for human skin. Healthy fats have omega-3 fatty acids, which are anti-inflammatory, and contain essential fatty acids plus fat soluble vitamins – A, D, E, and K – which can be helpful for skin. Grass fed-animals tend to have more omega-3 fatty acids, whereas grain-fed animals tend to have more omega-6 than omega-3 fatty acids.

Headdresses, traditional clothing, and adornments are seen in traditional Mongolia, particularly during the Naadam festival. With naturally high cheek bones and oval eyes that have epicanthic folds, many Mongolian women have distinct features. Long black braided hair is seen as an adornment during festivals. In rural Mongolia, it is not uncommon to see rosy red cheeks, flushed with telangiectasias due to sun, wind, and snow. In the capital city, the distinctive telangiectatic cheeks are not seen as frequently; instead, many women wear eyeliner to highlight their oval eyes. With my mother’s side of the family being direct descendants of Mongolia to the Middle East, I found these beauty practices to be fascinating and they hold a special place in my heart.
 

Dr. Wesley and Dr. Talakoub are co-contributors 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.

Resource:

1. J Altern Complement Med. 2015 Jul;21(7):380-5.

In a large country of only 3 million people (where wild horses outnumber people), with an estimated 2 million who live in the capital and 1 million who live a traditional nomadic lifestyle, traditional skin care and beauty practices can still be found.

In the capital city of Ulaanbaatar, women practice many of the same beauty regimens as those of women in other parts of mainstream Asia, with access to department store beauty counters and shopping malls found in major cities throughout the world. With the influx of movies and media into Mongolia from South Korea in the late 1990s, South Korean beauty regimens and standards have weaved their way into the urban culture. However, in rural Mongolia, where a nomadic way of life still predominates, certain beauty and cultural practices remain intact without the influence of mainstream culture.

While lucky enough to travel to rural Mongolia on a medical volunteer trip this summer, I was able to witness and inquire about some of these practices. I was extremely fortunate to meet and befriend a Mongolian woman, Tuvdendorj Dulguun, who shared some of these skin care secrets with me.

Homemade yogurt, a staple in rural Mongolia, is used on the face to help brighten the skin. In rural Mongolia, the yogurt is made and eaten fresh, thus lasts for 1-2 days if not refrigerated. The yogurt comes from cows and goats (rarely from other animals) that graze on open land without pesticides and are not fed hormones and grains. My personal diet doesn’t consist of much dairy, but I can say firsthand that in my opinion, it is delicious there. Yogurt is also applied to the skin to treat acne, but for acne the yogurt is fermented more than usual, so there is more acid to reduce the skin inflammation. (Lactic acid is typically what is found in fermented yogurt.)

Another secret is the use of sheep tail fat on the skin. A well fed sheep collects and stores a large amount of fat in the lower back and tail as an energy reserve – easily recognizable as a “fat bottom” on the animal. A mutton (older sheep only), when consumed, is typically prepared for special occasions, such as the new year’s festival “Tsagaan Sar” or a wedding. Sheep tail fat is thought to have more collagen and provide more moisturization than other beauty products, especially in the sometimes harsh, arid climate of Mongolia. This tradition is fading, but Tuvdendorj’s aunt still uses it and has beautiful skin. The fat in the sheep’s tail is full of nutrients, and is what’s used for human skin. Healthy fats have omega-3 fatty acids, which are anti-inflammatory, and contain essential fatty acids plus fat soluble vitamins – A, D, E, and K – which can be helpful for skin. Grass fed-animals tend to have more omega-3 fatty acids, whereas grain-fed animals tend to have more omega-6 than omega-3 fatty acids.

Headdresses, traditional clothing, and adornments are seen in traditional Mongolia, particularly during the Naadam festival. With naturally high cheek bones and oval eyes that have epicanthic folds, many Mongolian women have distinct features. Long black braided hair is seen as an adornment during festivals. In rural Mongolia, it is not uncommon to see rosy red cheeks, flushed with telangiectasias due to sun, wind, and snow. In the capital city, the distinctive telangiectatic cheeks are not seen as frequently; instead, many women wear eyeliner to highlight their oval eyes. With my mother’s side of the family being direct descendants of Mongolia to the Middle East, I found these beauty practices to be fascinating and they hold a special place in my heart.
 

Dr. Wesley and Dr. Talakoub are co-contributors 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.

Resource:

1. J Altern Complement Med. 2015 Jul;21(7):380-5.

 

Besides skin wrinkling, volume shifts, and photoaging, graying hair can also be a telltale sign of aging. While it was recently a fashionable trend for younger persons to dye their hair white or gray, graying hair can make a younger person appear older, even in those with naturally premature graying of the hair.

In a study recently published in Genes & Development, researchers at the University of Texas Southwestern Medical Center, Dallas, identified hair shaft progenitors in the matrix that are specific to the hair shaft and not to follicular epithelial cells.¹ These hair shaft progenitors express transcription factor KROX20, which expresses stem cell growth factor necessary for hair pigmentation by maintenance of differentiated melanocytes. When KROX20+ is depleted, hair growth is halted and hair turns gray, proving its important role in both hair growth and graying pathways.

Other mechanisms for hair graying include oxidative stress to the hair, at the level of the melanocyte stem cell or at the end-stage of the hair melanocyte, resulting in follicular melanocyte death. With aging and certain genetic mutations (such as that seen in Chediak-Higashi syndrome), reduction of catalase and sometimes downregulation of antioxidant proteins such as BCL-2 and TRP-2 are reduced, resulting in higher reactive oxygen species (ROS) that lead to bulbar melanocyte malfunction and death.

Last year, for the first time, researchers at University College of London identified a gene involved in gray hair, the interferon regulatory factor 4 gene (IRF4).² The IRF4 gene is involved in regulating production and storage of melanin.

Besides photoprotection and vitamin antioxidants as a preventive measure, therapies that have been developed to target the reduction of ROS in hair have been largely unsatisfactory in treating gray hair. Most people either allow their hair to gray or dye their hair, which can be time consuming and costly and is required on a more frequent basis over time – not to mention the distress related to allergic contact dermatitis caused by some components of some hair dyes, including paraphenylenediamine, which we sometimes see in our profession.

Knowledge of KROX20+, the IRF4 gene, and other pathways involved may be useful in developing novel treatments to prevent or treat graying hair. Information regarding the use of platelet rich plasma (PRP) for hair growth is increasingly being published in the literature. While some physicians purport seeing a reversal in graying with scalp PRP injections, the majority say the results are not universal.

Currently, there are no published studies evaluating the effects of PRP on gray hair. Perhaps providing stem cell factors via injections of PRP or other growth factors may aid not only in hair regrowth but in preserving pigmentation and repigmentation.

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. Genes Dev. 2017 May 2. doi: 10.1101/gad.298703.117.

2. Nat Commun. 2016 Mar 1;7:10815.

 

Besides skin wrinkling, volume shifts, and photoaging, graying hair can also be a telltale sign of aging. While it was recently a fashionable trend for younger persons to dye their hair white or gray, graying hair can make a younger person appear older, even in those with naturally premature graying of the hair.

In a study recently published in Genes & Development, researchers at the University of Texas Southwestern Medical Center, Dallas, identified hair shaft progenitors in the matrix that are specific to the hair shaft and not to follicular epithelial cells.¹ These hair shaft progenitors express transcription factor KROX20, which expresses stem cell growth factor necessary for hair pigmentation by maintenance of differentiated melanocytes. When KROX20+ is depleted, hair growth is halted and hair turns gray, proving its important role in both hair growth and graying pathways.

Other mechanisms for hair graying include oxidative stress to the hair, at the level of the melanocyte stem cell or at the end-stage of the hair melanocyte, resulting in follicular melanocyte death. With aging and certain genetic mutations (such as that seen in Chediak-Higashi syndrome), reduction of catalase and sometimes downregulation of antioxidant proteins such as BCL-2 and TRP-2 are reduced, resulting in higher reactive oxygen species (ROS) that lead to bulbar melanocyte malfunction and death.

Last year, for the first time, researchers at University College of London identified a gene involved in gray hair, the interferon regulatory factor 4 gene (IRF4).² The IRF4 gene is involved in regulating production and storage of melanin.

Besides photoprotection and vitamin antioxidants as a preventive measure, therapies that have been developed to target the reduction of ROS in hair have been largely unsatisfactory in treating gray hair. Most people either allow their hair to gray or dye their hair, which can be time consuming and costly and is required on a more frequent basis over time – not to mention the distress related to allergic contact dermatitis caused by some components of some hair dyes, including paraphenylenediamine, which we sometimes see in our profession.

Knowledge of KROX20+, the IRF4 gene, and other pathways involved may be useful in developing novel treatments to prevent or treat graying hair. Information regarding the use of platelet rich plasma (PRP) for hair growth is increasingly being published in the literature. While some physicians purport seeing a reversal in graying with scalp PRP injections, the majority say the results are not universal.

Currently, there are no published studies evaluating the effects of PRP on gray hair. Perhaps providing stem cell factors via injections of PRP or other growth factors may aid not only in hair regrowth but in preserving pigmentation and repigmentation.

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. Genes Dev. 2017 May 2. doi: 10.1101/gad.298703.117.

2. Nat Commun. 2016 Mar 1;7:10815.

 

Besides skin wrinkling, volume shifts, and photoaging, graying hair can also be a telltale sign of aging. While it was recently a fashionable trend for younger persons to dye their hair white or gray, graying hair can make a younger person appear older, even in those with naturally premature graying of the hair.

In a study recently published in Genes & Development, researchers at the University of Texas Southwestern Medical Center, Dallas, identified hair shaft progenitors in the matrix that are specific to the hair shaft and not to follicular epithelial cells.¹ These hair shaft progenitors express transcription factor KROX20, which expresses stem cell growth factor necessary for hair pigmentation by maintenance of differentiated melanocytes. When KROX20+ is depleted, hair growth is halted and hair turns gray, proving its important role in both hair growth and graying pathways.

Other mechanisms for hair graying include oxidative stress to the hair, at the level of the melanocyte stem cell or at the end-stage of the hair melanocyte, resulting in follicular melanocyte death. With aging and certain genetic mutations (such as that seen in Chediak-Higashi syndrome), reduction of catalase and sometimes downregulation of antioxidant proteins such as BCL-2 and TRP-2 are reduced, resulting in higher reactive oxygen species (ROS) that lead to bulbar melanocyte malfunction and death.

Last year, for the first time, researchers at University College of London identified a gene involved in gray hair, the interferon regulatory factor 4 gene (IRF4).² The IRF4 gene is involved in regulating production and storage of melanin.

Besides photoprotection and vitamin antioxidants as a preventive measure, therapies that have been developed to target the reduction of ROS in hair have been largely unsatisfactory in treating gray hair. Most people either allow their hair to gray or dye their hair, which can be time consuming and costly and is required on a more frequent basis over time – not to mention the distress related to allergic contact dermatitis caused by some components of some hair dyes, including paraphenylenediamine, which we sometimes see in our profession.

Knowledge of KROX20+, the IRF4 gene, and other pathways involved may be useful in developing novel treatments to prevent or treat graying hair. Information regarding the use of platelet rich plasma (PRP) for hair growth is increasingly being published in the literature. While some physicians purport seeing a reversal in graying with scalp PRP injections, the majority say the results are not universal.

Currently, there are no published studies evaluating the effects of PRP on gray hair. Perhaps providing stem cell factors via injections of PRP or other growth factors may aid not only in hair regrowth but in preserving pigmentation and repigmentation.

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. Genes Dev. 2017 May 2. doi: 10.1101/gad.298703.117.

2. Nat Commun. 2016 Mar 1;7:10815.

 

Observational studies suggest that hard water is associated with the development of atopic dermatitis (AD). Studies of children in the United Kingdom, Spain, and Japan show the prevalence of AD is significantly higher in the highest water hardness categories than that in the lowest. Calcium cations in water can interfere with normal epidermal calcium gradients that are necessary for corneocyte development and proper stratum corneum barrier formation.

Water hardness, determined by the amount of dissolved calcium and magnesium in the water, varies by geography and mineral content of the water supply. The hardest water supply in the United States is mostly localized to the Upper Plains and Rocky Mountain areas. General guidelines for classification of waters are: 0-60 mg/L calcium carbonate (soft); 61-120 mg/L (moderately hard); 121-180 mg/L (hard); and more than 180 mg/L (very hard). In regions where there is hard water, the surfactants in soap, such as sodium dodecyl sulfate, react with the calcium and magnesium ions in hard water, resulting in precipitation of the surfactant – leaving a film of residue on the skin, shower tiles, pipes, glassware, etc.

Maibach et al. also described water as a contact irritant, particularly under occlusion. Skin occluded with water has increased histopathologic inflammation, scaling, and barrier breakdown. In addition to than mineral content, pH, temperature, and osmolarity can be contributing factors to the irritancy of water. However, compared with “soft water,” skin exposed to hard water has increased dilution of the natural moisturizing factors and alteration of the corneocyte layers, resulting in increased disruption of the protective epidermal barrier.

Atopic dermatitis, xerosis, and pruritus are some of the common skin reactions to hard water. Other less-well-defined effects on the skin include clogged pores and acne from surfactant residue left on the skin and altered sebum production. In addition, more surfactants or cleansers are needed to clean the skin and hair in areas with hard water because the abundant cations require a much heavier lather to dissolve.

Calcium and magnesium cations left on the skin can also form free radicals. Free radicals over time can result in collagen and elastin breakdown and in the increased prevalence of fine lines and wrinkles.

Although there is no definitive solution to geographic increases of water mineral content, water softeners have grown in popularity over the last decade and in my practice are recommended to anyone with atopic dermatitis that is resistant to treatment or is recalcitrant. These home appliances work though an ion exchange system in which a resin or organic polymer replaces the magnesium and calcium in the water with sodium or potassium cations. When all the sodium or potassium ions have been replaced in the resin, the resin is then “recharged” with a solution of sodium hydroxide (lye) or potassium hydroxide. Alternative less popular softening techniques include lime softening, chelating agents, distillation, and reverse osmosis.

Hard water and geography should be considered a possible factor when assessing patients with recalcitrant eczema, pruritus, or xerosis that cannot otherwise be reversed. Water softening treatments are a simple solution in areas where the mineral content of water is elevated or the water plays a role in clinical skin disease.


 

Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

United States Geological Survey Water Quality Information: Water Hardness and Alkalinity.

J Am Acad Dermatol. 1987 Jun;16(6):1263-4.

Contact Dermatitis. 1996 Dec;35(6):337-43.

Lancet. 1998 Aug 15;352(9127):527-31.

Contact Dermatitis. 1999;41(6):311-4.

Environ Res. 2004 Jan;94(1):33-7.

 

Observational studies suggest that hard water is associated with the development of atopic dermatitis (AD). Studies of children in the United Kingdom, Spain, and Japan show the prevalence of AD is significantly higher in the highest water hardness categories than that in the lowest. Calcium cations in water can interfere with normal epidermal calcium gradients that are necessary for corneocyte development and proper stratum corneum barrier formation.

Water hardness, determined by the amount of dissolved calcium and magnesium in the water, varies by geography and mineral content of the water supply. The hardest water supply in the United States is mostly localized to the Upper Plains and Rocky Mountain areas. General guidelines for classification of waters are: 0-60 mg/L calcium carbonate (soft); 61-120 mg/L (moderately hard); 121-180 mg/L (hard); and more than 180 mg/L (very hard). In regions where there is hard water, the surfactants in soap, such as sodium dodecyl sulfate, react with the calcium and magnesium ions in hard water, resulting in precipitation of the surfactant – leaving a film of residue on the skin, shower tiles, pipes, glassware, etc.

Maibach et al. also described water as a contact irritant, particularly under occlusion. Skin occluded with water has increased histopathologic inflammation, scaling, and barrier breakdown. In addition to than mineral content, pH, temperature, and osmolarity can be contributing factors to the irritancy of water. However, compared with “soft water,” skin exposed to hard water has increased dilution of the natural moisturizing factors and alteration of the corneocyte layers, resulting in increased disruption of the protective epidermal barrier.

Atopic dermatitis, xerosis, and pruritus are some of the common skin reactions to hard water. Other less-well-defined effects on the skin include clogged pores and acne from surfactant residue left on the skin and altered sebum production. In addition, more surfactants or cleansers are needed to clean the skin and hair in areas with hard water because the abundant cations require a much heavier lather to dissolve.

Calcium and magnesium cations left on the skin can also form free radicals. Free radicals over time can result in collagen and elastin breakdown and in the increased prevalence of fine lines and wrinkles.

Although there is no definitive solution to geographic increases of water mineral content, water softeners have grown in popularity over the last decade and in my practice are recommended to anyone with atopic dermatitis that is resistant to treatment or is recalcitrant. These home appliances work though an ion exchange system in which a resin or organic polymer replaces the magnesium and calcium in the water with sodium or potassium cations. When all the sodium or potassium ions have been replaced in the resin, the resin is then “recharged” with a solution of sodium hydroxide (lye) or potassium hydroxide. Alternative less popular softening techniques include lime softening, chelating agents, distillation, and reverse osmosis.

Hard water and geography should be considered a possible factor when assessing patients with recalcitrant eczema, pruritus, or xerosis that cannot otherwise be reversed. Water softening treatments are a simple solution in areas where the mineral content of water is elevated or the water plays a role in clinical skin disease.


 

Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

United States Geological Survey Water Quality Information: Water Hardness and Alkalinity.

J Am Acad Dermatol. 1987 Jun;16(6):1263-4.

Contact Dermatitis. 1996 Dec;35(6):337-43.

Lancet. 1998 Aug 15;352(9127):527-31.

Contact Dermatitis. 1999;41(6):311-4.

Environ Res. 2004 Jan;94(1):33-7.

 

Observational studies suggest that hard water is associated with the development of atopic dermatitis (AD). Studies of children in the United Kingdom, Spain, and Japan show the prevalence of AD is significantly higher in the highest water hardness categories than that in the lowest. Calcium cations in water can interfere with normal epidermal calcium gradients that are necessary for corneocyte development and proper stratum corneum barrier formation.

Water hardness, determined by the amount of dissolved calcium and magnesium in the water, varies by geography and mineral content of the water supply. The hardest water supply in the United States is mostly localized to the Upper Plains and Rocky Mountain areas. General guidelines for classification of waters are: 0-60 mg/L calcium carbonate (soft); 61-120 mg/L (moderately hard); 121-180 mg/L (hard); and more than 180 mg/L (very hard). In regions where there is hard water, the surfactants in soap, such as sodium dodecyl sulfate, react with the calcium and magnesium ions in hard water, resulting in precipitation of the surfactant – leaving a film of residue on the skin, shower tiles, pipes, glassware, etc.

Maibach et al. also described water as a contact irritant, particularly under occlusion. Skin occluded with water has increased histopathologic inflammation, scaling, and barrier breakdown. In addition to than mineral content, pH, temperature, and osmolarity can be contributing factors to the irritancy of water. However, compared with “soft water,” skin exposed to hard water has increased dilution of the natural moisturizing factors and alteration of the corneocyte layers, resulting in increased disruption of the protective epidermal barrier.

Atopic dermatitis, xerosis, and pruritus are some of the common skin reactions to hard water. Other less-well-defined effects on the skin include clogged pores and acne from surfactant residue left on the skin and altered sebum production. In addition, more surfactants or cleansers are needed to clean the skin and hair in areas with hard water because the abundant cations require a much heavier lather to dissolve.

Calcium and magnesium cations left on the skin can also form free radicals. Free radicals over time can result in collagen and elastin breakdown and in the increased prevalence of fine lines and wrinkles.

Although there is no definitive solution to geographic increases of water mineral content, water softeners have grown in popularity over the last decade and in my practice are recommended to anyone with atopic dermatitis that is resistant to treatment or is recalcitrant. These home appliances work though an ion exchange system in which a resin or organic polymer replaces the magnesium and calcium in the water with sodium or potassium cations. When all the sodium or potassium ions have been replaced in the resin, the resin is then “recharged” with a solution of sodium hydroxide (lye) or potassium hydroxide. Alternative less popular softening techniques include lime softening, chelating agents, distillation, and reverse osmosis.

Hard water and geography should be considered a possible factor when assessing patients with recalcitrant eczema, pruritus, or xerosis that cannot otherwise be reversed. Water softening treatments are a simple solution in areas where the mineral content of water is elevated or the water plays a role in clinical skin disease.


 

Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.

References

United States Geological Survey Water Quality Information: Water Hardness and Alkalinity.

J Am Acad Dermatol. 1987 Jun;16(6):1263-4.

Contact Dermatitis. 1996 Dec;35(6):337-43.

Lancet. 1998 Aug 15;352(9127):527-31.

Contact Dermatitis. 1999;41(6):311-4.

Environ Res. 2004 Jan;94(1):33-7.

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

Judith Thomas, DDS, a dentist in Virginia who is trained in clinical hypnosis, once described the power of the word but. People will often put more emphasis in their minds on what is said after the word but than on what is said before. For example, in a romantic relationship context, saying “I love you, but you drive me crazy” has a different impact than “You drive me crazy, but I love you.” The focus tends to stay on the “I love you” portion more when it is said last, after the “but.”

The same phenomenon can happen when we discuss procedures with our patients. When a medical assistant performs phlebotomy or when we as doctors are about to perform an injection, instead of saying this is going to hurt, another way to phrase it would be “In a moment you may feel something, but it doesn’t have to bother you” or “You may experience some discomfort, but it will resolve quickly.” Something I’ve said for years to patients before surgery is “You may feel a little stinging as the anesthetic goes in, after that you may feel me touching you, but nothing uncomfortable.” I guess I had been intuitively using this technique for years, without knowing the impact of the word “but.” Perhaps now that I am more mindful of it, I will be even more mindful of how I phrase these terms. We, in addition to our nurses and medical assistants, can use these techniques to enhance patient comfort and the patient’s experience.
 

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

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. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.
 

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

Judith Thomas, DDS, a dentist in Virginia who is trained in clinical hypnosis, once described the power of the word but. People will often put more emphasis in their minds on what is said after the word but than on what is said before. For example, in a romantic relationship context, saying “I love you, but you drive me crazy” has a different impact than “You drive me crazy, but I love you.” The focus tends to stay on the “I love you” portion more when it is said last, after the “but.”

The same phenomenon can happen when we discuss procedures with our patients. When a medical assistant performs phlebotomy or when we as doctors are about to perform an injection, instead of saying this is going to hurt, another way to phrase it would be “In a moment you may feel something, but it doesn’t have to bother you” or “You may experience some discomfort, but it will resolve quickly.” Something I’ve said for years to patients before surgery is “You may feel a little stinging as the anesthetic goes in, after that you may feel me touching you, but nothing uncomfortable.” I guess I had been intuitively using this technique for years, without knowing the impact of the word “but.” Perhaps now that I am more mindful of it, I will be even more mindful of how I phrase these terms. We, in addition to our nurses and medical assistants, can use these techniques to enhance patient comfort and the patient’s experience.
 

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

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. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.
 

The words we choose to use prior to procedures can positively or negatively impact a patient’s experience during a procedure and their decision to have the procedure performed. A practical example would include using the word discomfort instead of pain to describe pain that may be associated with a procedure. The root word of discomfort is comfort, which the mind focuses on and creates less of an anxious state than pain.

Obviously, the need to provide proper and realistic expectations, as well as risks and benefits, is of utmost importance when obtaining informed consent. The words used can put a patient’s mind at ease or cause further anxiety about ideas of needles, scalpels, pain, risk of infection, and bleeding that are part of our everyday procedures.

Judith Thomas, DDS, a dentist in Virginia who is trained in clinical hypnosis, once described the power of the word but. People will often put more emphasis in their minds on what is said after the word but than on what is said before. For example, in a romantic relationship context, saying “I love you, but you drive me crazy” has a different impact than “You drive me crazy, but I love you.” The focus tends to stay on the “I love you” portion more when it is said last, after the “but.”

The same phenomenon can happen when we discuss procedures with our patients. When a medical assistant performs phlebotomy or when we as doctors are about to perform an injection, instead of saying this is going to hurt, another way to phrase it would be “In a moment you may feel something, but it doesn’t have to bother you” or “You may experience some discomfort, but it will resolve quickly.” Something I’ve said for years to patients before surgery is “You may feel a little stinging as the anesthetic goes in, after that you may feel me touching you, but nothing uncomfortable.” I guess I had been intuitively using this technique for years, without knowing the impact of the word “but.” Perhaps now that I am more mindful of it, I will be even more mindful of how I phrase these terms. We, in addition to our nurses and medical assistants, can use these techniques to enhance patient comfort and the patient’s experience.
 

According to the American Society of Clinical Hypnosis, physicians and dentists used the power of words through hypnosis as anesthesia before the first chemical general anesthetic agent, ether, was used for surgery in the 1840s, followed by chloroform. Prior to this time, British and Scottish physicians John Elliotson, James Esdaile, and James Braid performed over 3,000 procedures and surgeries with clinical hypnosis alone. Some may argue that the ancient Egyptians also used hypnosis for their well-described surgeries, as no other anesthetic has been documented. Moreover, there is evidence of “sleep temples” that the ancient Egyptians used for healing.¹

This article is not to suggest that our words should replace anesthesia. Many advances in anesthesia and pain control have been made since the time of chloroform. However, being mindful of our words can aid and assist in our surgical and aesthetic procedures where less anesthesia is used: Patients feel more comfortable, they heal faster, and overall, they have a more positive outcome and pleasant physician-patient experience.²

For patients, the skill of the doctor and the outcome of the procedure are of the utmost importance, but, especially in aesthetic dermatology, where some of our procedures are repeated or performed periodically, the positive impact of the entire experience will entrust them with your care long term.

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. Mutter, C.B. (1998). History of Hypnosis. (pp. 10-12) “Hypnotic Induction and Suggestion.” Chicago: American Society of Clinical Hypnosis.

2. Burns. 2010 Aug;36(5):639-46.