Naissan Wesley, MD

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Resources:

American Society for Plastic Surgery 2012 statistics.

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

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

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

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

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

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

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

Resources:

American Society for Plastic Surgery 2012 statistics.

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

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

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

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

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

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

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

Resources:

American Society for Plastic Surgery 2012 statistics.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.

Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.

If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).

In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.

I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m²), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).

Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.

Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.

If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).

In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.

I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m²), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).

Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Cryolipolysis has emerged as a popular noninvasive treatment option for reducing localized areas of fat. The technology was developed on the premise that cold temperatures can selectively damage subcutaneous fat while leaving the overlying skin unharmed, as demonstrated by popsicle panniculitis. In this process, when subcutaneous fat is cooled below body temperature but above freezing, the fat undergoes cell death followed by a local inflammatory response, a localized panniculitis, that gradually results in a reduction of fat in that area.

Dr. Dieter Manstein and Dr. R. Rox Anderson pioneered the concept of cryolipolysis in 2008. The technology was approved by the Food and Drug Administration in 2010 in the form of the Zeltiq device. The device has different-sized hand pieces with a vacuum connection that, after it is applied to the skin, cools the subcutaneous fat without damaging the top layers of skin. Each area is treated for 1 hour, and 20%-30% of the fat cells are expected to be reduced with a single treatment. Typical responses after treatment include numbness, but some patients may also experience bruising and discomfort, all of which typically last no longer than 2-3 weeks.

If discomfort occurs in my patients, I find they report it more often in the lower abdomen than the love handles. Paradoxical adipose hyperplasia was recently reported for the first time in a male patient in his 40s (in the lower abdomen) (JAMA Dermatol. 2014;150:317-9).

In my experience, there is no difference in efficacy or adverse events seen in patients of different ethnicities. One study found no difference in efficacy or adverse events of cryolipolysis in Chinese patients (Lasers Surg. Med. 2012;44:125-30), but no other study of cryolipolysis in ethnic patients has been published.

I was involved in the clinical trials for this device prior to FDA approval where one love handle was treated on a patient and the other side was used as a control. Based on this experience and my experience using the device in practice, it is not a replacement for abdominoplasty or liposuction, but it is a useful technology in the right candidate. The patients who seem to do the best are those who are 10-15 pounds from their goal weight, are not obese (body mass index less than 30 kg/m²), and have a discrete bulge (typically love handles or abdomen) that they can’t get rid of with good diet and exercise alone. Massage for a few minutes after treatment seems to increase efficacy (Lasers Surg. Med. 2014;46:20-6).

Some patients may require more than one treatment to achieve their desired results, but I recommend waiting at least 2-3 months before opting for additional treatment. Choosing the right candidates and providing patients with realistic expectations seem to be the most helpful in this process.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dyschromias are one of the most common skin concerns among women and persons of color. In the April issue of Journal of Drugs in Dermatology, Dr. S.J. Kang and associates conducted an excellent study to determine whether racial or ethnic groups are treated differently for dyschromia.

The investigators searched the National Ambulatory Medical Care Survey (NAMCS) database for visits including the diagnosis of dyschromia (ICD-9 codes 709.00 or 709.09) during an 18-year period (1993-2010). They found 24.7 million visits for dyschromia and 5,531,000 patients with a sole diagnosis of dyschromia. Of those with a sole diagnosis of dyschromia, 76% were seen by a dermatologist, and more than half were female. Seventy-five percent were white, 11% African American, 7% Asian/Pacific Islander, and 9% Hispanic, although Asians demonstrated the highest number of visits per 100,000 persons.

In this review, hydroquinone monotherapy was the most commonly prescribed medication by dermatologists. Combination therapy with hydroquinone plus a retinoid and corticosteroid was utilized for women 10 times more than for men. African American patients were less likely to be prescribed combination therapy or receive procedures (such as cryotherapy, chemical peels or lasers). Additionally, sunscreens were recommended less often to black and Asian patients, compared with white patients.

While the underlying reason for dyschromia plays a role in the type of treatment given, overall combination therapies are often more effective than therapy with hydroquinone alone. This study demonstrates that combination therapy may be under-utilized in patients of color.

In my practice, I find that unless the patient’s skin is completely hydroquinone-naive, combination therapy with hydroquinone, retinoid, and corticosteroid is often a first-line treatment that may achieve faster results. Sun protection is a vital component in the treatment of dyschromia, and it is recommended for every patient, regardless of race or ethnicity. Nonhydroquinone topical agents containing ingredients such as kojic acid, arbutin, licorice, niacinamide, resveratrol, and superficial chemical peels are also used in all ethnic groups. In my Asian, Hispanic, and African American or darker-skinned patients, I do use caution with deeper peels and lasers and often perform a test spot first if this type of therapy is considered.

Dr. Wesley practices dermatology in Beverly Hills, Calif.

Dry skin occurs throughout the year, but for many people it’s most prevalent and problematic in winter. Cold temperatures, low humidity, and strong, harsh winds deplete the skin of its natural lipid layer, which would normally help keep the skin from drying out. Skin of color in particular, can become very flaky, dry, and "ashy" in the winter. Differences in the stratum corneum barrier in skin of color may contribute to the propensity toward ashiness.

The barrier function of the skin depends on the structure of the corneocytes, lipid content, and transepidermal water loss. Compared with skin in white people, black skin has more corneocyte layers and a more compact stratum corneum with greater intercellular cohesiveness. The epidermal barrier in darker skin has been shown to be stronger when exposed to mechanical or chemical challenge. Although the size of the individual corneocytes is the same in black and white skin, the desquamation rate in certain locations is higher in black skin. This is likely due to increased desquamatory enzyme levels such as cathepsin L2 in the lamellar granules of darker pigmented individuals leading to an ashy manifestation of the skin.

Black skin also has the highest sebum content of all ethnicities, but has the lowest ceramide level, and is thus the most susceptible to transepidermal water loss and xerosis of any ethnic group. Of note, one study has shown that the use of a certain type of fatty acid body wash or a synthetic "syndet" bar reduced ashiness.

Although no large, multiethnic group studies have been performed to examine the skin barrier physiologic properties and their relation to clinical signs of disease, these small studies do shed light on some of the ethnic variation in skin barrier function.

In clinical practice, these small variations should play a role in personalized treatment regimens for common conditions such as acne and atopic dermatitis. In my practice, black patients with acne often have high sebum content, but they cannot tolerate drying medications such as benzoyl peroxide because of their skin sensitivity and intolerance to skin drying. These patients often also present with ashy, dry skin in certain areas, and oily, acne-prone skin in other areas, leading to more complex skin care regimens. Understanding these basic concepts can help better tailor our basic skin treatments and education for skin of color patients in the winter and throughout the year.

Sources:

Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin. Cutan. Med. Surg. 2009;28:115-29.

Feng L, Hawkins S. Reduction of "ashiness" in skin of color with a lipid-rich moisturizing body wash. J. Clin. Aesthet. Dermatol. 2011;4:41-4.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Dry skin occurs throughout the year, but for many people it’s most prevalent and problematic in winter. Cold temperatures, low humidity, and strong, harsh winds deplete the skin of its natural lipid layer, which would normally help keep the skin from drying out. Skin of color in particular, can become very flaky, dry, and "ashy" in the winter. Differences in the stratum corneum barrier in skin of color may contribute to the propensity toward ashiness.

The barrier function of the skin depends on the structure of the corneocytes, lipid content, and transepidermal water loss. Compared with skin in white people, black skin has more corneocyte layers and a more compact stratum corneum with greater intercellular cohesiveness. The epidermal barrier in darker skin has been shown to be stronger when exposed to mechanical or chemical challenge. Although the size of the individual corneocytes is the same in black and white skin, the desquamation rate in certain locations is higher in black skin. This is likely due to increased desquamatory enzyme levels such as cathepsin L2 in the lamellar granules of darker pigmented individuals leading to an ashy manifestation of the skin.

Black skin also has the highest sebum content of all ethnicities, but has the lowest ceramide level, and is thus the most susceptible to transepidermal water loss and xerosis of any ethnic group. Of note, one study has shown that the use of a certain type of fatty acid body wash or a synthetic "syndet" bar reduced ashiness.

Although no large, multiethnic group studies have been performed to examine the skin barrier physiologic properties and their relation to clinical signs of disease, these small studies do shed light on some of the ethnic variation in skin barrier function.

In clinical practice, these small variations should play a role in personalized treatment regimens for common conditions such as acne and atopic dermatitis. In my practice, black patients with acne often have high sebum content, but they cannot tolerate drying medications such as benzoyl peroxide because of their skin sensitivity and intolerance to skin drying. These patients often also present with ashy, dry skin in certain areas, and oily, acne-prone skin in other areas, leading to more complex skin care regimens. Understanding these basic concepts can help better tailor our basic skin treatments and education for skin of color patients in the winter and throughout the year.

Sources:

Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin. Cutan. Med. Surg. 2009;28:115-29.

Feng L, Hawkins S. Reduction of "ashiness" in skin of color with a lipid-rich moisturizing body wash. J. Clin. Aesthet. Dermatol. 2011;4:41-4.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Dry skin occurs throughout the year, but for many people it’s most prevalent and problematic in winter. Cold temperatures, low humidity, and strong, harsh winds deplete the skin of its natural lipid layer, which would normally help keep the skin from drying out. Skin of color in particular, can become very flaky, dry, and "ashy" in the winter. Differences in the stratum corneum barrier in skin of color may contribute to the propensity toward ashiness.

The barrier function of the skin depends on the structure of the corneocytes, lipid content, and transepidermal water loss. Compared with skin in white people, black skin has more corneocyte layers and a more compact stratum corneum with greater intercellular cohesiveness. The epidermal barrier in darker skin has been shown to be stronger when exposed to mechanical or chemical challenge. Although the size of the individual corneocytes is the same in black and white skin, the desquamation rate in certain locations is higher in black skin. This is likely due to increased desquamatory enzyme levels such as cathepsin L2 in the lamellar granules of darker pigmented individuals leading to an ashy manifestation of the skin.

Black skin also has the highest sebum content of all ethnicities, but has the lowest ceramide level, and is thus the most susceptible to transepidermal water loss and xerosis of any ethnic group. Of note, one study has shown that the use of a certain type of fatty acid body wash or a synthetic "syndet" bar reduced ashiness.

Although no large, multiethnic group studies have been performed to examine the skin barrier physiologic properties and their relation to clinical signs of disease, these small studies do shed light on some of the ethnic variation in skin barrier function.

In clinical practice, these small variations should play a role in personalized treatment regimens for common conditions such as acne and atopic dermatitis. In my practice, black patients with acne often have high sebum content, but they cannot tolerate drying medications such as benzoyl peroxide because of their skin sensitivity and intolerance to skin drying. These patients often also present with ashy, dry skin in certain areas, and oily, acne-prone skin in other areas, leading to more complex skin care regimens. Understanding these basic concepts can help better tailor our basic skin treatments and education for skin of color patients in the winter and throughout the year.

Sources:

Talakoub L, Wesley NO. Differences in perceptions of beauty and cosmetic procedures performed in ethnic patients. Semin. Cutan. Med. Surg. 2009;28:115-29.

Feng L, Hawkins S. Reduction of "ashiness" in skin of color with a lipid-rich moisturizing body wash. J. Clin. Aesthet. Dermatol. 2011;4:41-4.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Pseudofolliculitis barbae (PFB) is a common complaint among darker-skinned patients with coarse curly hair. Patients present with follicular papules in the beard from ingrown hairs that can eventually result in postinflammatory pigmentary alternation and scarring. While these symptoms are most common in men, women may be affected as well, as PFB is not limited to the beard area; it may occur in any other area with thick, coarse curly hair, including the bikini area and axillae.

Some tips for treating PFB:

If the patient doesn’t mind growing a beard, advise him to grow one! The chances of having ingrown hairs that stimulate this condition are less if the hairs are not plucked or shaved, or are kept at least a few millimeters long.

If hair removal/grooming is a must, options include clipping the hairs with a protector; using a self-cleaning electric razor (replacing the blades at least every 2 years); and using thick shaving gel with either a single or twin blade razor, or a chemical depilatory.

Laser hair removal is also an option in the right candidate, particularly with longer pulsed (1,064 nm or 810 nm) lasers in darker-skinned individuals. Eflornithine 12% twice daily for 16 weeks has been shown to work synergistically with laser hair removal. Electrolysis may be helpful for hairs that do not respond to laser hair removal with longer pulsed lasers, such as grey hairs.

If shaving is a must, advise patients to:

• Apply warm compresses to the beard area for a few minutes prior to shaving. In addition, using a mild exfoliant or loofah or toothbrush in a circular motion will help allow any ingrown hairs to be more easily plucked or released at the skin surface.

• Use shaving gel and a sharp razor each time.

• Do not pull the skin taut.

• Do not shave against the direction of hair growth.

• Take short strokes and do not shave back and forth over the same areas.

• After shaving, use a soothing aftershave or hydrocortisone 1% lotion.

Products such as PFB Vanish, which contain salicylic, glycolic, and/or lactic acid, are helpful in some patients after hair removal to prevent ingrown hairs. One version of PFB Vanish contains antipigment ingredients to also address hyperpigmentation.

If inflammatory papules or pustules are present, a combination benzoyl peroxide/clindamycin topical gels (such as Benzaclin, Duac, or Acanya) can be used. Patients with severe inflammation may require oral antibiotics.

Using a topical retinoid at night or a combination retinoid product with hydroquinone can be helpful especially in cases of postinflammatory hyperpigmentation. However, use caution when prescribing retinoids for patients with darker skin, as irritation from these products may lead to postinflammatory pigmentary alteration. Remind patients to avoid drying products, such as toners, if topical retinoids are used.

For severe or refractory postinflammatory hyperpigmentation or inflammatory papules, chemical peels with 20%-30% salicylic acid can be helpful.

What are your PFB solutions? The more we share our clinical insights, the better we will be able to achieve improved treatment results for our patients.

Dr. Wesley practices dermatology in Beverly Hills, Calif. Do you have questions about treating patients with dark skin? If so, send them to [email protected].