American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS): Annual Meeting

The skin care market may pull in $9 billion per year, but three cosmeceutical experts agreed that the best over-the-counter antiaging products come down to two words: "moisturizer" and "sunscreen."

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur, and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Sherry Boschert/Elsevier Global Medical News

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of antiaging effectiveness. When evidence does exist, it generally points back to the moisturizer and sunscreen properties.

Dr. Draelos, a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University in Durham, N.C., studied the ingredients in over-the-counter skin care products. She found that 80% of products are basically moisturizers that serve as a vehicle to deliver a high-profile ingredient being touted by the manufacturer (Plast. Reconstr. Surg. 2010;125:719-24).

"Hands down, it’s the moisturizer" that’s the most important cosmeceutical choice, she said. "All the products that make antiaging claims are making moisturizer claims," and most antiaging products also have sunscreen ingredients in them.

Dr. Michael Gold said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it’s $700."

Dr. Gold, the founder and medical director of a skin care center based in Nashville, Tenn., urged his colleagues, "If you dispense, do it ethically."

Dermatologists have an important role to play by assessing the marketing claims of cosmeceuticals, not just listening to them. "Even though we don’t have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, who is also president of the ASCDAS.

She took that approach in her book, written with Gina Way, "Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin" (Atria Books, 2009). The book "perhaps put me at odds with some of the industry, but we’re challenging them to produce better science," she said.

Dr. Marmur and her associates are conducting the first independent, randomized, blinded, controlled trial comparing over-the-counter antiaging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the people who apply the products blinded to the product being used.

Not all antiaging cream manufacturers are included, however, "Some brands refused to participate" perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that observation during a question-and-answer session. "The industry doesn’t want closer scrutiny," she said.

Dr. Draelos also spoke at the 2011 Skin Disease Education Foundation's Women's and Pediatric Dermatology Seminar. She said she recommends that her patients start with a moisturizer containing dimethicone, glycerin, or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said.

For antiaging, she suggested recommending sunscreens containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals.

How does that translate into over-the-counter product recommendations for patients? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson’s Aveeno Positively Radiant Daily Moisturizer SPF 30, and for the body, she suggests Galderma’s Cetaphil Cream.

In separate interviews, the three dermatologists agreed that more research is needed on the efficacy of cosmeceuticals, and delved into the nuances of ingredients in antiaging skin-care regimens. They also agreed that dermatologists need to be patients’ advocates and educators first and foremost.

Moisturizers and sunscreen undoubtedly are the main ingredients in most cosmeceutical regimens, but there are good data to support other ingredients, said Dr. Paul F. Lizzul of Tufts Medical Center, Boston. Randomized clinical trials have shown that retinoids, for example, can be beneficial, but patients probably are better served by prescription-strength retinoids to get "a better bang for their buck," compared with over-the-counter products, he said.

For other cosmeceutical ingredients, however, there may be in vitro or in vivo data but no rigorous clinical studies to back them up. "Even as a well-trained academic dermatologist with an extensive scientific and clinical research background, I, at times, am at a loss to understand the claims made by some cosmeceutical manufacturers," he said.

Dr. Lizzul does not believe that most of the questionable "active ingredients" penetrate the stratum corneum to be able to have the claimed effects on the dermis or epidermis. In some cases, if the ingredient magically penetrated to the dermis, it could be harmful, not helpful, he added.

"It is curious to me that at many of our meetings, research presented to support product claims is oftentimes no more than anecdotal evidence. If you critically look at the presentation and the actual data, you would be remiss to believe that product X actually works," he said.

On the other hand, the lack of double-blind studies of a particular product or ingredient does not mean that it isn’t helpful. By reviewing the biochemistry, basic science, and clinical observations of a treatment, dermatologists can steer patients toward a potential treatment, said Dr. Wendy E. Roberts, a dermatologist in Rancho Mirage, Calif.

She compared her approach to cosmeceuticals to the correlations she makes as a dermatopathologist. "Under the microscope it could be many things, but you match it with the clinical information and come up with a diagnosis. We can kind of use that model with cosmeceuticals," she said. "With our expertise, we know that there’s this body of evidence, we know the activity, and we have our living lab, which is our patients [whom we] see every day. Those observations can lead to further observations."

Many reports in the medical literature describe antiaging benefits from ingredients like peptides, vitamin C, alpha and beta hydroxy acids, lactic acid, retinol, niacinamide, and other ingredients, which can be incorporated into moisturizer formulas, Dr. Roberts said.

Although the three pillars of cosmeceutical regimens are cleansers, moisturizers, and sunscreen, limiting the discussion to those vague terms is "so 1990s," she said. "As a cosmetic dermatologist, it is my job to be able to know the science of a product and recommend the cosmeceutical for that skin type. Working in the capital of sun-damaged skin, I see how certain cosmeceuticals alone can improve skin qualities."

Dr. Leslie Baumann of Miami Beach also said that ingredients other than moisturizer and sunscreen are necessary, depending on the patient’s skin type. She has patients complete a questionnaire to help determine skin type, and matches ingredients to that type.

Sensitive skin types, for example, need anti-inflammatory ingredients, she said. Aged skin benefits from retinoids. Lighteners can help skin with unwanted pigment.

Dermatologists have an ethical responsibility to advise patients on the best cosmeceutical options and on more affordable options if they exist. "Sometimes cheaper products will suffice, and sometimes they will not," Dr. Baumann said.

Dr. Draelos has been a consultant and researcher for Avon, Dial, Johnson & Johnson, L’Oréal, Nu Skin, Procter & Gamble, and Stiefel. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

Dr. Roberts has had financial relationships with Allergan, Johnson & Johnson, L’Oréal, La Roche–Posay, and Ortho Dermatologics. Dr. Baumann has led or participated in research trials for more than 50 cosmetic and pharmaceutical companies. Dr. Lizzul had no relevant disclosures.

SDEF and this news organization are owned by Elsevier.

The skin care market may pull in $9 billion per year, but three cosmeceutical experts agreed that the best over-the-counter antiaging products come down to two words: "moisturizer" and "sunscreen."

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur, and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Sherry Boschert/Elsevier Global Medical News

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of antiaging effectiveness. When evidence does exist, it generally points back to the moisturizer and sunscreen properties.

Dr. Draelos, a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University in Durham, N.C., studied the ingredients in over-the-counter skin care products. She found that 80% of products are basically moisturizers that serve as a vehicle to deliver a high-profile ingredient being touted by the manufacturer (Plast. Reconstr. Surg. 2010;125:719-24).

"Hands down, it’s the moisturizer" that’s the most important cosmeceutical choice, she said. "All the products that make antiaging claims are making moisturizer claims," and most antiaging products also have sunscreen ingredients in them.

Dr. Michael Gold said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it’s $700."

Dr. Gold, the founder and medical director of a skin care center based in Nashville, Tenn., urged his colleagues, "If you dispense, do it ethically."

Dermatologists have an important role to play by assessing the marketing claims of cosmeceuticals, not just listening to them. "Even though we don’t have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, who is also president of the ASCDAS.

She took that approach in her book, written with Gina Way, "Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin" (Atria Books, 2009). The book "perhaps put me at odds with some of the industry, but we’re challenging them to produce better science," she said.

Dr. Marmur and her associates are conducting the first independent, randomized, blinded, controlled trial comparing over-the-counter antiaging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the people who apply the products blinded to the product being used.

Not all antiaging cream manufacturers are included, however, "Some brands refused to participate" perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that observation during a question-and-answer session. "The industry doesn’t want closer scrutiny," she said.

Dr. Draelos also spoke at the 2011 Skin Disease Education Foundation's Women's and Pediatric Dermatology Seminar. She said she recommends that her patients start with a moisturizer containing dimethicone, glycerin, or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said.

For antiaging, she suggested recommending sunscreens containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals.

How does that translate into over-the-counter product recommendations for patients? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson’s Aveeno Positively Radiant Daily Moisturizer SPF 30, and for the body, she suggests Galderma’s Cetaphil Cream.

In separate interviews, the three dermatologists agreed that more research is needed on the efficacy of cosmeceuticals, and delved into the nuances of ingredients in antiaging skin-care regimens. They also agreed that dermatologists need to be patients’ advocates and educators first and foremost.

Moisturizers and sunscreen undoubtedly are the main ingredients in most cosmeceutical regimens, but there are good data to support other ingredients, said Dr. Paul F. Lizzul of Tufts Medical Center, Boston. Randomized clinical trials have shown that retinoids, for example, can be beneficial, but patients probably are better served by prescription-strength retinoids to get "a better bang for their buck," compared with over-the-counter products, he said.

For other cosmeceutical ingredients, however, there may be in vitro or in vivo data but no rigorous clinical studies to back them up. "Even as a well-trained academic dermatologist with an extensive scientific and clinical research background, I, at times, am at a loss to understand the claims made by some cosmeceutical manufacturers," he said.

Dr. Lizzul does not believe that most of the questionable "active ingredients" penetrate the stratum corneum to be able to have the claimed effects on the dermis or epidermis. In some cases, if the ingredient magically penetrated to the dermis, it could be harmful, not helpful, he added.

"It is curious to me that at many of our meetings, research presented to support product claims is oftentimes no more than anecdotal evidence. If you critically look at the presentation and the actual data, you would be remiss to believe that product X actually works," he said.

On the other hand, the lack of double-blind studies of a particular product or ingredient does not mean that it isn’t helpful. By reviewing the biochemistry, basic science, and clinical observations of a treatment, dermatologists can steer patients toward a potential treatment, said Dr. Wendy E. Roberts, a dermatologist in Rancho Mirage, Calif.

She compared her approach to cosmeceuticals to the correlations she makes as a dermatopathologist. "Under the microscope it could be many things, but you match it with the clinical information and come up with a diagnosis. We can kind of use that model with cosmeceuticals," she said. "With our expertise, we know that there’s this body of evidence, we know the activity, and we have our living lab, which is our patients [whom we] see every day. Those observations can lead to further observations."

Many reports in the medical literature describe antiaging benefits from ingredients like peptides, vitamin C, alpha and beta hydroxy acids, lactic acid, retinol, niacinamide, and other ingredients, which can be incorporated into moisturizer formulas, Dr. Roberts said.

Although the three pillars of cosmeceutical regimens are cleansers, moisturizers, and sunscreen, limiting the discussion to those vague terms is "so 1990s," she said. "As a cosmetic dermatologist, it is my job to be able to know the science of a product and recommend the cosmeceutical for that skin type. Working in the capital of sun-damaged skin, I see how certain cosmeceuticals alone can improve skin qualities."

Dr. Leslie Baumann of Miami Beach also said that ingredients other than moisturizer and sunscreen are necessary, depending on the patient’s skin type. She has patients complete a questionnaire to help determine skin type, and matches ingredients to that type.

Sensitive skin types, for example, need anti-inflammatory ingredients, she said. Aged skin benefits from retinoids. Lighteners can help skin with unwanted pigment.

Dermatologists have an ethical responsibility to advise patients on the best cosmeceutical options and on more affordable options if they exist. "Sometimes cheaper products will suffice, and sometimes they will not," Dr. Baumann said.

Dr. Draelos has been a consultant and researcher for Avon, Dial, Johnson & Johnson, L’Oréal, Nu Skin, Procter & Gamble, and Stiefel. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

Dr. Roberts has had financial relationships with Allergan, Johnson & Johnson, L’Oréal, La Roche–Posay, and Ortho Dermatologics. Dr. Baumann has led or participated in research trials for more than 50 cosmetic and pharmaceutical companies. Dr. Lizzul had no relevant disclosures.

SDEF and this news organization are owned by Elsevier.

The skin care market may pull in $9 billion per year, but three cosmeceutical experts agreed that the best over-the-counter antiaging products come down to two words: "moisturizer" and "sunscreen."

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur, and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Sherry Boschert/Elsevier Global Medical News

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of antiaging effectiveness. When evidence does exist, it generally points back to the moisturizer and sunscreen properties.

Dr. Draelos, a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University in Durham, N.C., studied the ingredients in over-the-counter skin care products. She found that 80% of products are basically moisturizers that serve as a vehicle to deliver a high-profile ingredient being touted by the manufacturer (Plast. Reconstr. Surg. 2010;125:719-24).

"Hands down, it’s the moisturizer" that’s the most important cosmeceutical choice, she said. "All the products that make antiaging claims are making moisturizer claims," and most antiaging products also have sunscreen ingredients in them.

Dr. Michael Gold said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it’s $700."

Dr. Gold, the founder and medical director of a skin care center based in Nashville, Tenn., urged his colleagues, "If you dispense, do it ethically."

Dermatologists have an important role to play by assessing the marketing claims of cosmeceuticals, not just listening to them. "Even though we don’t have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, who is also president of the ASCDAS.

She took that approach in her book, written with Gina Way, "Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin" (Atria Books, 2009). The book "perhaps put me at odds with some of the industry, but we’re challenging them to produce better science," she said.

Dr. Marmur and her associates are conducting the first independent, randomized, blinded, controlled trial comparing over-the-counter antiaging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the people who apply the products blinded to the product being used.

Not all antiaging cream manufacturers are included, however, "Some brands refused to participate" perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that observation during a question-and-answer session. "The industry doesn’t want closer scrutiny," she said.

Dr. Draelos also spoke at the 2011 Skin Disease Education Foundation's Women's and Pediatric Dermatology Seminar. She said she recommends that her patients start with a moisturizer containing dimethicone, glycerin, or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said.

For antiaging, she suggested recommending sunscreens containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals.

How does that translate into over-the-counter product recommendations for patients? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson’s Aveeno Positively Radiant Daily Moisturizer SPF 30, and for the body, she suggests Galderma’s Cetaphil Cream.

In separate interviews, the three dermatologists agreed that more research is needed on the efficacy of cosmeceuticals, and delved into the nuances of ingredients in antiaging skin-care regimens. They also agreed that dermatologists need to be patients’ advocates and educators first and foremost.

Moisturizers and sunscreen undoubtedly are the main ingredients in most cosmeceutical regimens, but there are good data to support other ingredients, said Dr. Paul F. Lizzul of Tufts Medical Center, Boston. Randomized clinical trials have shown that retinoids, for example, can be beneficial, but patients probably are better served by prescription-strength retinoids to get "a better bang for their buck," compared with over-the-counter products, he said.

For other cosmeceutical ingredients, however, there may be in vitro or in vivo data but no rigorous clinical studies to back them up. "Even as a well-trained academic dermatologist with an extensive scientific and clinical research background, I, at times, am at a loss to understand the claims made by some cosmeceutical manufacturers," he said.

Dr. Lizzul does not believe that most of the questionable "active ingredients" penetrate the stratum corneum to be able to have the claimed effects on the dermis or epidermis. In some cases, if the ingredient magically penetrated to the dermis, it could be harmful, not helpful, he added.

"It is curious to me that at many of our meetings, research presented to support product claims is oftentimes no more than anecdotal evidence. If you critically look at the presentation and the actual data, you would be remiss to believe that product X actually works," he said.

On the other hand, the lack of double-blind studies of a particular product or ingredient does not mean that it isn’t helpful. By reviewing the biochemistry, basic science, and clinical observations of a treatment, dermatologists can steer patients toward a potential treatment, said Dr. Wendy E. Roberts, a dermatologist in Rancho Mirage, Calif.

She compared her approach to cosmeceuticals to the correlations she makes as a dermatopathologist. "Under the microscope it could be many things, but you match it with the clinical information and come up with a diagnosis. We can kind of use that model with cosmeceuticals," she said. "With our expertise, we know that there’s this body of evidence, we know the activity, and we have our living lab, which is our patients [whom we] see every day. Those observations can lead to further observations."

Many reports in the medical literature describe antiaging benefits from ingredients like peptides, vitamin C, alpha and beta hydroxy acids, lactic acid, retinol, niacinamide, and other ingredients, which can be incorporated into moisturizer formulas, Dr. Roberts said.

Although the three pillars of cosmeceutical regimens are cleansers, moisturizers, and sunscreen, limiting the discussion to those vague terms is "so 1990s," she said. "As a cosmetic dermatologist, it is my job to be able to know the science of a product and recommend the cosmeceutical for that skin type. Working in the capital of sun-damaged skin, I see how certain cosmeceuticals alone can improve skin qualities."

Dr. Leslie Baumann of Miami Beach also said that ingredients other than moisturizer and sunscreen are necessary, depending on the patient’s skin type. She has patients complete a questionnaire to help determine skin type, and matches ingredients to that type.

Sensitive skin types, for example, need anti-inflammatory ingredients, she said. Aged skin benefits from retinoids. Lighteners can help skin with unwanted pigment.

Dermatologists have an ethical responsibility to advise patients on the best cosmeceutical options and on more affordable options if they exist. "Sometimes cheaper products will suffice, and sometimes they will not," Dr. Baumann said.

Dr. Draelos has been a consultant and researcher for Avon, Dial, Johnson & Johnson, L’Oréal, Nu Skin, Procter & Gamble, and Stiefel. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

Dr. Roberts has had financial relationships with Allergan, Johnson & Johnson, L’Oréal, La Roche–Posay, and Ortho Dermatologics. Dr. Baumann has led or participated in research trials for more than 50 cosmetic and pharmaceutical companies. Dr. Lizzul had no relevant disclosures.

SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.

LAS VEGAS – Off-label use of hyaluronic acid fillers can help reposition aging eyes for a younger look.

As bones of the orbital socket dissolve with age, the globe of the eyeball descends and shifts laterally, shifting the balance of the gaze. Permanent fillers such as silicone have been used in the retro-orbital space to lift up the globe, but that doesn’t help move the globe from a lateral to a more medial position, Dr. Ellen S. Marmur said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

For a typical patient who has malar flattening and complains of looking tired all the time, Dr. Marmur uses a "two-point technique." She injects two perpendicular boluses of hyaluronic acid filler under the muscles below each eye and molds the filler upward.

She starts medially to the infraorbital foramen and stays deep, using the fewest injections to cause the fewest bruises and to give a smooth finish.

For patients who are older, she may extend the two-point technique into a five-point technique or even a circumferential technique.

"I start medially and then continue on laterally throughout the upper cheek, all the way up to near the medial canthus," said Dr. Marmur of Mount Sinai School of Medicine, New York. It’s hard to stay under the muscle all the way, so she injects using a threading technique with the bevel down so the filler is being pushed down.

Even dermatologists who are experienced in these techniques will cause bruising in approximately half of patients, she said. The worst bruising and swelling happens in the lateral aspect of the orbit because of the vessels and the histamine released there.

"You should be worried about occlusion, so try to avoid the vasculature," Dr. Marmur said.

If there is lidocaine in the injections, it will numb some of the muscle and the area might get "a little bit twitchy" during the injection.

"Once you fill these areas, you realize it’s a continuum and you want to go around" the lateral orbit itself, she said. "Some people get almost a little ‘V’ of the lateral canthus. Just filling that in also helps reassert the nice dimension and the width of the gaze and makes people look a little less serious. We start looking really serious when we’re getting older."

The eyes are considered a "danger zone" of the face because injections can tract bacteria into the cavernous sinus, she cautioned. "I’ve never seen it happen, and it hasn’t been reported, but be very clean in the area."

Filler injections also can produce a Tyndall effect, a discoloration that can get worse as the filler degrades. "I’m not exactly sure why that is," said Dr. Marmur, adding that she looks forward to newer hyaluronic acid fillers that won’t show the blue hue.

Injections also can take on a "festoonlike appearance," caused either by the filler itself or when the filler grabs water that needs to be massaged away, she said.

Dr. Marmur always talks to patients about the option of using hyaluronidase to reverse the hyaluronic acid filler. "There’s no shame in having it in your office and using it whenever you want," she said. "It’s a nice, comfortable option for people, especially if they’re doing their eyes for the first time.

Dermatologists will be learning from each other about which of the many approved hyaluronic acid fillers are good to use in different areas of the face, but the specialty really needs some well-designed, head-to-head, randomized trials comparing the strengths and weaknesses of these fillers, she said. The studies should compare the fillers for use in patients of different facial types and ages.

Planning cosmetic facial injections for aged patients involves thinking about how they may have looked when they were younger, and understanding the effects of aging, such as bone degradation, muscle thinning, skin laxity, and drooping fat. It also involves understanding the ideals of beauty that might be achieved without changing how the patient looks. Dermatologists also must commit themselves "to not overdoing it and not letting our patients push us into overdoing it," she said.

Dr. Marmur disclosed financial ties with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi-Aventis.

LAS VEGAS – More medical practices will be victims of embezzlement than not, so physicians must be on top of all financial affairs in their practice, said Dr. David A. Laub.

In a 2009 survey of members of the Medical Group Management Association, 83% of 945 respondents reported being affiliated with a medical practice that had been the victim of employee theft or embezzlement.

Given that figure, it’s important to have an accountant that can be trusted, ideally one who specializes in medical practices, and to monitor the accountant’s reports at least quarterly, Dr. David A. Laub said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If someone is embezzling, most often it’s the office manager, usually by taking copays and petty cash, said Dr. Laub. Secret bank accounts hurt the most, so be wary if someone from the office staff interrupts a busy day to have a form quickly signed with a brief rationale for opening another account.

"You need to be the one signing every check and the one reviewing the credit card statements. It’s a lot of work, but unfortunately you have to monitor this" as part of financial discipline, said Dr. Laub, who practices dermatology in Mill Valley, Calif.

He suggested watching for signs of embezzlement, such as disparities between billing and collections, or an increasing number of accounts written off as unpaid. If there are increasing overhead costs but not increasing revenues related to products, the embezzler may be taking the products. On the more blatant side, if your office manager shows up at work one day in a Jaguar or makes some other lavish lifestyle change – well, you have to wonder.

Other potential signs include disorganized books or computer entries, or an office manager who suggests changing accountants or who declines vacation time, perhaps hoping to stay in control and not get caught, he said. Be alert also for duplicate payables – checks already signed but the manager asks for another one to be signed, which gets altered later for the embezzler’s gain.

Another tip for preventing theft is to separate duties. The person who takes checks from the mail should not be the same one who enters the data into the computer, he said. Get an electronic time clock to stamp the date and time on everything. Design a system for inventory and review it monthly, either through electronic medical records or a ledger in the back office. Insist on signing all checks.

"As long as you show you’re interested and are following what’s going on, it will stop a lot of problems," Dr. Laub said.

From his experience running his solo practice with two* physician assistants, three medical assistants,* three staff members answering phones, a billing administrator, and an office manager, Dr. Laub offered another tip for running a successful practice: positive leadership.

"If I’m not in a good mood, it brings the staff down, and all of a sudden everybody is inefficient," he said. Enter the office with a smile and ask staff members how their morning or weekend went.

©Don Bayley/iStockphoto.com

To maintain his positive energy, Dr. Laub decided in his 40s to start taking a half-day off per week for each subsequent 5 years of practice. Now in his mid-50s, Dr. Laub is about to change from 4.5 to 4 days of work per week.

Dr. Laub said that when he first started a practice, all of his staff members were full-time employees, but he said that he has found a part-time staff is more efficient. Now his staff is composed of 80% part-time employees and 20% full-time employees, and they stay with him for 7 years on average. "These staffers are much happier," he said.

Offer complimentary staff treatments if possible, perhaps one treatment per quarter for each employee so they are exposed to services offered, he suggested.

Also, identify what’s important to individual staff members – professional growth, or getting home to the family each day – to help inform scheduling and goal setting. Praise staff publicly but critique them in private, always sandwiching criticisms between positive statements.

Dr. Laub did not disclose any conflicts of interest.

^{*03/26/2012 Information updated to reflect correct staff numbers and titles.}

LAS VEGAS – More medical practices will be victims of embezzlement than not, so physicians must be on top of all financial affairs in their practice, said Dr. David A. Laub.

In a 2009 survey of members of the Medical Group Management Association, 83% of 945 respondents reported being affiliated with a medical practice that had been the victim of employee theft or embezzlement.

Given that figure, it’s important to have an accountant that can be trusted, ideally one who specializes in medical practices, and to monitor the accountant’s reports at least quarterly, Dr. David A. Laub said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If someone is embezzling, most often it’s the office manager, usually by taking copays and petty cash, said Dr. Laub. Secret bank accounts hurt the most, so be wary if someone from the office staff interrupts a busy day to have a form quickly signed with a brief rationale for opening another account.

"You need to be the one signing every check and the one reviewing the credit card statements. It’s a lot of work, but unfortunately you have to monitor this" as part of financial discipline, said Dr. Laub, who practices dermatology in Mill Valley, Calif.

He suggested watching for signs of embezzlement, such as disparities between billing and collections, or an increasing number of accounts written off as unpaid. If there are increasing overhead costs but not increasing revenues related to products, the embezzler may be taking the products. On the more blatant side, if your office manager shows up at work one day in a Jaguar or makes some other lavish lifestyle change – well, you have to wonder.

Other potential signs include disorganized books or computer entries, or an office manager who suggests changing accountants or who declines vacation time, perhaps hoping to stay in control and not get caught, he said. Be alert also for duplicate payables – checks already signed but the manager asks for another one to be signed, which gets altered later for the embezzler’s gain.

Another tip for preventing theft is to separate duties. The person who takes checks from the mail should not be the same one who enters the data into the computer, he said. Get an electronic time clock to stamp the date and time on everything. Design a system for inventory and review it monthly, either through electronic medical records or a ledger in the back office. Insist on signing all checks.

"As long as you show you’re interested and are following what’s going on, it will stop a lot of problems," Dr. Laub said.

From his experience running his solo practice with two* physician assistants, three medical assistants,* three staff members answering phones, a billing administrator, and an office manager, Dr. Laub offered another tip for running a successful practice: positive leadership.

"If I’m not in a good mood, it brings the staff down, and all of a sudden everybody is inefficient," he said. Enter the office with a smile and ask staff members how their morning or weekend went.

©Don Bayley/iStockphoto.com

To maintain his positive energy, Dr. Laub decided in his 40s to start taking a half-day off per week for each subsequent 5 years of practice. Now in his mid-50s, Dr. Laub is about to change from 4.5 to 4 days of work per week.

Dr. Laub said that when he first started a practice, all of his staff members were full-time employees, but he said that he has found a part-time staff is more efficient. Now his staff is composed of 80% part-time employees and 20% full-time employees, and they stay with him for 7 years on average. "These staffers are much happier," he said.

Offer complimentary staff treatments if possible, perhaps one treatment per quarter for each employee so they are exposed to services offered, he suggested.

Also, identify what’s important to individual staff members – professional growth, or getting home to the family each day – to help inform scheduling and goal setting. Praise staff publicly but critique them in private, always sandwiching criticisms between positive statements.

Dr. Laub did not disclose any conflicts of interest.

^{*03/26/2012 Information updated to reflect correct staff numbers and titles.}

LAS VEGAS – More medical practices will be victims of embezzlement than not, so physicians must be on top of all financial affairs in their practice, said Dr. David A. Laub.

In a 2009 survey of members of the Medical Group Management Association, 83% of 945 respondents reported being affiliated with a medical practice that had been the victim of employee theft or embezzlement.

Given that figure, it’s important to have an accountant that can be trusted, ideally one who specializes in medical practices, and to monitor the accountant’s reports at least quarterly, Dr. David A. Laub said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

If someone is embezzling, most often it’s the office manager, usually by taking copays and petty cash, said Dr. Laub. Secret bank accounts hurt the most, so be wary if someone from the office staff interrupts a busy day to have a form quickly signed with a brief rationale for opening another account.

"You need to be the one signing every check and the one reviewing the credit card statements. It’s a lot of work, but unfortunately you have to monitor this" as part of financial discipline, said Dr. Laub, who practices dermatology in Mill Valley, Calif.

He suggested watching for signs of embezzlement, such as disparities between billing and collections, or an increasing number of accounts written off as unpaid. If there are increasing overhead costs but not increasing revenues related to products, the embezzler may be taking the products. On the more blatant side, if your office manager shows up at work one day in a Jaguar or makes some other lavish lifestyle change – well, you have to wonder.

Other potential signs include disorganized books or computer entries, or an office manager who suggests changing accountants or who declines vacation time, perhaps hoping to stay in control and not get caught, he said. Be alert also for duplicate payables – checks already signed but the manager asks for another one to be signed, which gets altered later for the embezzler’s gain.

Another tip for preventing theft is to separate duties. The person who takes checks from the mail should not be the same one who enters the data into the computer, he said. Get an electronic time clock to stamp the date and time on everything. Design a system for inventory and review it monthly, either through electronic medical records or a ledger in the back office. Insist on signing all checks.

"As long as you show you’re interested and are following what’s going on, it will stop a lot of problems," Dr. Laub said.

From his experience running his solo practice with two* physician assistants, three medical assistants,* three staff members answering phones, a billing administrator, and an office manager, Dr. Laub offered another tip for running a successful practice: positive leadership.

"If I’m not in a good mood, it brings the staff down, and all of a sudden everybody is inefficient," he said. Enter the office with a smile and ask staff members how their morning or weekend went.

©Don Bayley/iStockphoto.com

To maintain his positive energy, Dr. Laub decided in his 40s to start taking a half-day off per week for each subsequent 5 years of practice. Now in his mid-50s, Dr. Laub is about to change from 4.5 to 4 days of work per week.

Dr. Laub said that when he first started a practice, all of his staff members were full-time employees, but he said that he has found a part-time staff is more efficient. Now his staff is composed of 80% part-time employees and 20% full-time employees, and they stay with him for 7 years on average. "These staffers are much happier," he said.

Offer complimentary staff treatments if possible, perhaps one treatment per quarter for each employee so they are exposed to services offered, he suggested.

Also, identify what’s important to individual staff members – professional growth, or getting home to the family each day – to help inform scheduling and goal setting. Praise staff publicly but critique them in private, always sandwiching criticisms between positive statements.

Dr. Laub did not disclose any conflicts of interest.

^{*03/26/2012 Information updated to reflect correct staff numbers and titles.}

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

Three of the top experts on cosmeceuticals agreed that the best over-the-counter, anti-aging products come down to two simple words: "moisturizer" and "sunscreen."

There is oh, so much more out there being sold in the $9 billion/year skin care market, much of which are anti-aging products. But the skin regimen that provides the biggest bang for the buck: moisturizer and sunscreen. Spend $100 on a product, and chances are its moisturizer and sunscreen anyway.

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of anti-aging effectiveness. When evidence does exist, it generally points back to – you guessed it – moisturizer and sunscreen.

Dr. Draelos a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University, studied the ingredients in over-the-counter skin care products. She found that 80% of products are moisturizers that serve as a vehicle to deliver whichever high-profile ingredient is being touted by the manufacturer (Plast. Reconst. Surg. 2010;125:719-24).

"Hands down, it's the moisturizer" that's the most important cosmeceutical choice, she said. "All the products that make anti-aging claims are making moisturizer claims," and most anti-aging products also have sunscreen ingredients in them.

When Dr. Gold first spoke at a medical conference many years ago about selling cosmeceutical products in his practice, most dermatologists frowned on the idea. He said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it's $700."

Dr. Gold, who is based in Nashville, urged his colleagues, "If you dispense, do it ethically." 

Dermatologists have an important role to play by not just listening to marketing claims of cosmeceuticals, but assessing them. "Even though we don't have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, and president of the ASCDAS.

She took that approach in her book, written with Gina Way, Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin (Atria Books, 2009). 

The book "perhaps put me at odds with some of the industry, but we're challenging them to produce better science," she said. 

Dr. Marmur and her associates are conducting the first randomized, controlled trial comparing over-the-counter anti-aging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the patients who apply the products blinded to the product being used.

Not all anti-aging cream manufacturers are included, however. "Some brands refused to participate," perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that idea during the question-and-answer session: "The industry doesn't want closer scrutiny," she said.  

I also heard Dr. Draelos speak recently at the Skin Disease and Education Foundation's Women's and Pediatric Dermatology Seminar. Her recommendations for cosmeceuticals include starting with a moisturizer containing dimethicone, glycerin, and/or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said. For anti-aging, she suggests a sunscreen containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals. 

How does that translate into over-the-counter products? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson's Aveeno Positively Radiant Daily Moisturizer SPF 30. And for the body, Galderma's Cetaphil cream. 

Dr. Draelos has been a consultant and researcher for Johnson & Johnson, L'Oreal, Procter & Gamble, Nu Skin, Avon, Stiefel, and Dial Corp. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

SDEF and this news organization are owned by Elsevier.

- Sherry Boschert

Three of the top experts on cosmeceuticals agreed that the best over-the-counter, anti-aging products come down to two simple words: "moisturizer" and "sunscreen."

There is oh, so much more out there being sold in the $9 billion/year skin care market, much of which are anti-aging products. But the skin regimen that provides the biggest bang for the buck: moisturizer and sunscreen. Spend $100 on a product, and chances are its moisturizer and sunscreen anyway.

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of anti-aging effectiveness. When evidence does exist, it generally points back to – you guessed it – moisturizer and sunscreen.

Dr. Draelos a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University, studied the ingredients in over-the-counter skin care products. She found that 80% of products are moisturizers that serve as a vehicle to deliver whichever high-profile ingredient is being touted by the manufacturer (Plast. Reconst. Surg. 2010;125:719-24).

"Hands down, it's the moisturizer" that's the most important cosmeceutical choice, she said. "All the products that make anti-aging claims are making moisturizer claims," and most anti-aging products also have sunscreen ingredients in them.

When Dr. Gold first spoke at a medical conference many years ago about selling cosmeceutical products in his practice, most dermatologists frowned on the idea. He said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it's $700."

Dr. Gold, who is based in Nashville, urged his colleagues, "If you dispense, do it ethically." 

Dermatologists have an important role to play by not just listening to marketing claims of cosmeceuticals, but assessing them. "Even though we don't have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, and president of the ASCDAS.

She took that approach in her book, written with Gina Way, Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin (Atria Books, 2009). 

The book "perhaps put me at odds with some of the industry, but we're challenging them to produce better science," she said. 

Dr. Marmur and her associates are conducting the first randomized, controlled trial comparing over-the-counter anti-aging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the patients who apply the products blinded to the product being used.

Not all anti-aging cream manufacturers are included, however. "Some brands refused to participate," perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that idea during the question-and-answer session: "The industry doesn't want closer scrutiny," she said.  

I also heard Dr. Draelos speak recently at the Skin Disease and Education Foundation's Women's and Pediatric Dermatology Seminar. Her recommendations for cosmeceuticals include starting with a moisturizer containing dimethicone, glycerin, and/or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said. For anti-aging, she suggests a sunscreen containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals. 

How does that translate into over-the-counter products? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson's Aveeno Positively Radiant Daily Moisturizer SPF 30. And for the body, Galderma's Cetaphil cream. 

Dr. Draelos has been a consultant and researcher for Johnson & Johnson, L'Oreal, Procter & Gamble, Nu Skin, Avon, Stiefel, and Dial Corp. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

SDEF and this news organization are owned by Elsevier.

- Sherry Boschert

Three of the top experts on cosmeceuticals agreed that the best over-the-counter, anti-aging products come down to two simple words: "moisturizer" and "sunscreen."

There is oh, so much more out there being sold in the $9 billion/year skin care market, much of which are anti-aging products. But the skin regimen that provides the biggest bang for the buck: moisturizer and sunscreen. Spend $100 on a product, and chances are its moisturizer and sunscreen anyway.

Speaking in separate presentations at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery (ASCDAS), Dr. Zoe D. Draelos, Dr. Ellen S. Marmur and Dr. Michael H. Gold agreed that there is little science to back up claims made by cosmeceutical companies.

Cosmeceuticals fall somewhere between cosmetics and pharmaceuticals; therefore, they are not regulated, and manufacturers are not required to show evidence of anti-aging effectiveness. When evidence does exist, it generally points back to – you guessed it – moisturizer and sunscreen.

Dr. Draelos a dermatologist in High Point, N.C., and a consulting professor of dermatology at Duke University, studied the ingredients in over-the-counter skin care products. She found that 80% of products are moisturizers that serve as a vehicle to deliver whichever high-profile ingredient is being touted by the manufacturer (Plast. Reconst. Surg. 2010;125:719-24).

"Hands down, it's the moisturizer" that's the most important cosmeceutical choice, she said. "All the products that make anti-aging claims are making moisturizer claims," and most anti-aging products also have sunscreen ingredients in them.

When Dr. Gold first spoke at a medical conference many years ago about selling cosmeceutical products in his practice, most dermatologists frowned on the idea. He said he has been dispensing cosmeceuticals for 22 years and has seen the market explode. "There is now a $700 moisturizer," he said. "There may be no difference" between that and a $10 moisturizer, "but some people will pay the $700 because it's $700."

Dr. Gold, who is based in Nashville, urged his colleagues, "If you dispense, do it ethically." 

Dermatologists have an important role to play by not just listening to marketing claims of cosmeceuticals, but assessing them. "Even though we don't have a lot of good research right now, patients want something their doctor feels good about," said Dr. Marmur of Mount Sinai School of Medicine, New York, and president of the ASCDAS.

She took that approach in her book, written with Gina Way, Simple Skin Beauty: Every Woman’s Guide to a Lifetime of Healthy, Gorgeous Skin (Atria Books, 2009). 

The book "perhaps put me at odds with some of the industry, but we're challenging them to produce better science," she said. 

Dr. Marmur and her associates are conducting the first randomized, controlled trial comparing over-the-counter anti-aging creams. With more than 130 subjects enrolled, the study will evaluate 28 biomarkers in seven lines of products, with the patients who apply the products blinded to the product being used.

Not all anti-aging cream manufacturers are included, however. "Some brands refused to participate," perhaps because they were afraid that the study would show that their product is effective but is a pharmaceutical, she said.

Dr. Draelos echoed that idea during the question-and-answer session: "The industry doesn't want closer scrutiny," she said.  

I also heard Dr. Draelos speak recently at the Skin Disease and Education Foundation's Women's and Pediatric Dermatology Seminar. Her recommendations for cosmeceuticals include starting with a moisturizer containing dimethicone, glycerin, and/or petrolatum. "The most robust moisturizer known to man has these three ingredients," she said. For anti-aging, she suggests a sunscreen containing avobenzone, oxybenzone, octocrylene, reflecting spheres, or antioxidant botanicals. 

How does that translate into over-the-counter products? For hands, Dr. Draelos favors Neutrogena Norwegian Formula Hand Cream. For the face, she recommends Johnson & Johnson's Aveeno Positively Radiant Daily Moisturizer SPF 30. And for the body, Galderma's Cetaphil cream. 

Dr. Draelos has been a consultant and researcher for Johnson & Johnson, L'Oreal, Procter & Gamble, Nu Skin, Avon, Stiefel, and Dial Corp. Dr. Marmur disclosed financial relationships with Allergan, DUSA Pharmaceuticals, Genentech, Medicis, Merz, and Sanofi Aventis. Dr. Gold has been a consultant or researcher for Allergan, Medicis, Mentor (Johnson & Johnson), Merz, Galderma, and numerous other companies.

SDEF and this news organization are owned by Elsevier.

- Sherry Boschert

LAS VEGAS – Endovenous laser therapy is replacing ligation and vein stripping for many patients with superficial venous incompetence, especially in the legs.

"The endovenous laser has been a major revolutionary advance in the treatment of medical varicose veins of the lower extremities," Dr. Neil S. Sadick said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Endovenous laser fibers are inserted in the vessel under ultrasound guidance to eradicate truncal varicosities in the short and lower saphenous veins. The laser heat transfer causes shrinkage of the vein wall collagen and decreased lumen, with the shrinkage proportional to the delivered linear endovenous energy density.

Photos courtesy Dr. Neil S. Sadick

"This is an extremely easy procedure," that takes about 15 minutes, said Dr. Sadick, a dermatologist at Weill Cornell Medical Center in New York. "It’s almost bloodless. Patients can go back to work that day" wearing light compression hose, and "there’s very little discomfort after" the procedure.

Recurrence rates with endovenous laser therapy also are lower, compared with conventional invasive surgical ligation and stripping procedures, he added. Studies by Dr. Sadick and his associates showed that recurrence rates after treatment of superficial venous incompetence with a combination of endovascular laser and ambulatory phlebectomy were approximately 6% at 1 year, 4% at 2 years, 3% at 3 years, and 4% at 4 years.

Endovenous laser therapy "induces an endothelial type of thrombosis, and then the vein gets dissolved by the body," he said.

Treatment Algorithm

Dr. Sadick developed an algorithm for treatment based on the type of leg varicosity. He uses endovenous laser therapy or endovenous radiofrequency technology to treat large varicose veins of the axial junctions, such as in the long or short saphenous veins. Most intermediate-size varicose veins, such as truncal varicosities or perforations, can be treated by either ambulatory phlebectomy or foam sclerotherapy.

For reticular veins, he prefers to treat with an external 1064-nm Nd:YAG (neodymium YAG) laser or sclerotherapy with or without foam. Microtelangiectasia, or "very, very small vessels," can be treated with microsclerotherapy via very dilute concentrations of sclerosant, "but this is where an external 1064-nm Nd:YAG laser plays an important role" and may suffice without microsclerotherapy, he said.

"Not all leg veins are treated equally," he added. Red telangiectasias measuring less than 1 mm in tiny, oxygenated, red vessels usually are superficial and are "hit hard" with short pulse durations of high-fluence external laser energy in small spot sizes of 1-2 mm.

For more bluish veins that measure 1-2 mm (which he called blue venulectasia) and for larger reticular varicosities that are 2-4 mm, spot sizes and pulse durations increase but with more moderate fluences. External laser settings for blue venulectasia would be a spot size of 2-4 mm with a medium pulse width and moderately high fluence. For reticular veins, he uses an external spot size of 4-6 mm with a long pulse width and moderate fluence.

"You can see excellent results if you use this paradigm of variable pulse moding for treating telangiectasia without even injecting patients," he said.

Lasers are indicated for the cosmetic treatment of leg veins in patients whose veins are too small to cannulize for sclerotherapy, or for the small subset of patients who do not respond to sclerotherapy. Patients with needle phobia or those who have multiple sclerosant allergies also are candidates for cosmetic laser treatment of leg veins.

Leg veins require different treatment than do facial telangiectasias, Dr. Sadick added. Hydrostatic pressure is greater in the legs. Lower extremity vessels are larger, with increased basal lamina, compared with facial telangiectasias. The deeper location of many lower-extremity vessels makes access more difficult.

Caution Is Advised

The longer wavelengths and higher fluences of external laser treatment for leg veins cause a greater inflammatory reaction. "The worst thing you can do is treat patients on a weekly or biweekly basis" with external laser, he said. "You need to wait 6-8 weeks after each laser treatment so all the inflammation can resolve before the next treatment session" in order to avoid complications.

Dr. Sadick cautioned that the external 1064-nm Nd:YAG lasers are "sort of like weapons. They need to be handled very gently and understood, particularly when you’re treating the legs." Complications can include ulceration, purpura, blisters, and hyper- or hypopigmentation. These most commonly are caused by stacking pulses in a given area (especially with longer wavelengths), treating tanned skin, improperly matching wavelength to skin type, and failing to address hydrostatic pressure.

"If you use a short wavelength laser like a pulsed dye laser for a dark-skinned individual, for sure you’re going to get hypopigmentation and potential scarring," he said. Avoid laser treatment in patients who have larger vessels feeding the spider telangiectasia, because the hydrostatic pressure increases the risk for side effects.

The clinical goals of laser therapy for leg telangiectasia are to treat vasospasm, erythema, and urticaria. "It’s important to understand the end points of therapy. You don’t need to treat these veins until the vessels go away," he said.

Dr. Sadick has consulted for or received research grants from Cutera, Cynosure, Palomar, Solta Medical, and Syneron.

LAS VEGAS – Endovenous laser therapy is replacing ligation and vein stripping for many patients with superficial venous incompetence, especially in the legs.

"The endovenous laser has been a major revolutionary advance in the treatment of medical varicose veins of the lower extremities," Dr. Neil S. Sadick said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Endovenous laser fibers are inserted in the vessel under ultrasound guidance to eradicate truncal varicosities in the short and lower saphenous veins. The laser heat transfer causes shrinkage of the vein wall collagen and decreased lumen, with the shrinkage proportional to the delivered linear endovenous energy density.

Photos courtesy Dr. Neil S. Sadick

"This is an extremely easy procedure," that takes about 15 minutes, said Dr. Sadick, a dermatologist at Weill Cornell Medical Center in New York. "It’s almost bloodless. Patients can go back to work that day" wearing light compression hose, and "there’s very little discomfort after" the procedure.

Recurrence rates with endovenous laser therapy also are lower, compared with conventional invasive surgical ligation and stripping procedures, he added. Studies by Dr. Sadick and his associates showed that recurrence rates after treatment of superficial venous incompetence with a combination of endovascular laser and ambulatory phlebectomy were approximately 6% at 1 year, 4% at 2 years, 3% at 3 years, and 4% at 4 years.

Endovenous laser therapy "induces an endothelial type of thrombosis, and then the vein gets dissolved by the body," he said.

Treatment Algorithm

Dr. Sadick developed an algorithm for treatment based on the type of leg varicosity. He uses endovenous laser therapy or endovenous radiofrequency technology to treat large varicose veins of the axial junctions, such as in the long or short saphenous veins. Most intermediate-size varicose veins, such as truncal varicosities or perforations, can be treated by either ambulatory phlebectomy or foam sclerotherapy.

For reticular veins, he prefers to treat with an external 1064-nm Nd:YAG (neodymium YAG) laser or sclerotherapy with or without foam. Microtelangiectasia, or "very, very small vessels," can be treated with microsclerotherapy via very dilute concentrations of sclerosant, "but this is where an external 1064-nm Nd:YAG laser plays an important role" and may suffice without microsclerotherapy, he said.

"Not all leg veins are treated equally," he added. Red telangiectasias measuring less than 1 mm in tiny, oxygenated, red vessels usually are superficial and are "hit hard" with short pulse durations of high-fluence external laser energy in small spot sizes of 1-2 mm.

For more bluish veins that measure 1-2 mm (which he called blue venulectasia) and for larger reticular varicosities that are 2-4 mm, spot sizes and pulse durations increase but with more moderate fluences. External laser settings for blue venulectasia would be a spot size of 2-4 mm with a medium pulse width and moderately high fluence. For reticular veins, he uses an external spot size of 4-6 mm with a long pulse width and moderate fluence.

"You can see excellent results if you use this paradigm of variable pulse moding for treating telangiectasia without even injecting patients," he said.

Lasers are indicated for the cosmetic treatment of leg veins in patients whose veins are too small to cannulize for sclerotherapy, or for the small subset of patients who do not respond to sclerotherapy. Patients with needle phobia or those who have multiple sclerosant allergies also are candidates for cosmetic laser treatment of leg veins.

Leg veins require different treatment than do facial telangiectasias, Dr. Sadick added. Hydrostatic pressure is greater in the legs. Lower extremity vessels are larger, with increased basal lamina, compared with facial telangiectasias. The deeper location of many lower-extremity vessels makes access more difficult.

Caution Is Advised

The longer wavelengths and higher fluences of external laser treatment for leg veins cause a greater inflammatory reaction. "The worst thing you can do is treat patients on a weekly or biweekly basis" with external laser, he said. "You need to wait 6-8 weeks after each laser treatment so all the inflammation can resolve before the next treatment session" in order to avoid complications.

Dr. Sadick cautioned that the external 1064-nm Nd:YAG lasers are "sort of like weapons. They need to be handled very gently and understood, particularly when you’re treating the legs." Complications can include ulceration, purpura, blisters, and hyper- or hypopigmentation. These most commonly are caused by stacking pulses in a given area (especially with longer wavelengths), treating tanned skin, improperly matching wavelength to skin type, and failing to address hydrostatic pressure.

"If you use a short wavelength laser like a pulsed dye laser for a dark-skinned individual, for sure you’re going to get hypopigmentation and potential scarring," he said. Avoid laser treatment in patients who have larger vessels feeding the spider telangiectasia, because the hydrostatic pressure increases the risk for side effects.

The clinical goals of laser therapy for leg telangiectasia are to treat vasospasm, erythema, and urticaria. "It’s important to understand the end points of therapy. You don’t need to treat these veins until the vessels go away," he said.

Dr. Sadick has consulted for or received research grants from Cutera, Cynosure, Palomar, Solta Medical, and Syneron.

LAS VEGAS – Endovenous laser therapy is replacing ligation and vein stripping for many patients with superficial venous incompetence, especially in the legs.

"The endovenous laser has been a major revolutionary advance in the treatment of medical varicose veins of the lower extremities," Dr. Neil S. Sadick said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Endovenous laser fibers are inserted in the vessel under ultrasound guidance to eradicate truncal varicosities in the short and lower saphenous veins. The laser heat transfer causes shrinkage of the vein wall collagen and decreased lumen, with the shrinkage proportional to the delivered linear endovenous energy density.

Photos courtesy Dr. Neil S. Sadick

"This is an extremely easy procedure," that takes about 15 minutes, said Dr. Sadick, a dermatologist at Weill Cornell Medical Center in New York. "It’s almost bloodless. Patients can go back to work that day" wearing light compression hose, and "there’s very little discomfort after" the procedure.

Recurrence rates with endovenous laser therapy also are lower, compared with conventional invasive surgical ligation and stripping procedures, he added. Studies by Dr. Sadick and his associates showed that recurrence rates after treatment of superficial venous incompetence with a combination of endovascular laser and ambulatory phlebectomy were approximately 6% at 1 year, 4% at 2 years, 3% at 3 years, and 4% at 4 years.

Endovenous laser therapy "induces an endothelial type of thrombosis, and then the vein gets dissolved by the body," he said.

Treatment Algorithm

Dr. Sadick developed an algorithm for treatment based on the type of leg varicosity. He uses endovenous laser therapy or endovenous radiofrequency technology to treat large varicose veins of the axial junctions, such as in the long or short saphenous veins. Most intermediate-size varicose veins, such as truncal varicosities or perforations, can be treated by either ambulatory phlebectomy or foam sclerotherapy.

For reticular veins, he prefers to treat with an external 1064-nm Nd:YAG (neodymium YAG) laser or sclerotherapy with or without foam. Microtelangiectasia, or "very, very small vessels," can be treated with microsclerotherapy via very dilute concentrations of sclerosant, "but this is where an external 1064-nm Nd:YAG laser plays an important role" and may suffice without microsclerotherapy, he said.

"Not all leg veins are treated equally," he added. Red telangiectasias measuring less than 1 mm in tiny, oxygenated, red vessels usually are superficial and are "hit hard" with short pulse durations of high-fluence external laser energy in small spot sizes of 1-2 mm.

For more bluish veins that measure 1-2 mm (which he called blue venulectasia) and for larger reticular varicosities that are 2-4 mm, spot sizes and pulse durations increase but with more moderate fluences. External laser settings for blue venulectasia would be a spot size of 2-4 mm with a medium pulse width and moderately high fluence. For reticular veins, he uses an external spot size of 4-6 mm with a long pulse width and moderate fluence.

"You can see excellent results if you use this paradigm of variable pulse moding for treating telangiectasia without even injecting patients," he said.

Lasers are indicated for the cosmetic treatment of leg veins in patients whose veins are too small to cannulize for sclerotherapy, or for the small subset of patients who do not respond to sclerotherapy. Patients with needle phobia or those who have multiple sclerosant allergies also are candidates for cosmetic laser treatment of leg veins.

Leg veins require different treatment than do facial telangiectasias, Dr. Sadick added. Hydrostatic pressure is greater in the legs. Lower extremity vessels are larger, with increased basal lamina, compared with facial telangiectasias. The deeper location of many lower-extremity vessels makes access more difficult.

Caution Is Advised

The longer wavelengths and higher fluences of external laser treatment for leg veins cause a greater inflammatory reaction. "The worst thing you can do is treat patients on a weekly or biweekly basis" with external laser, he said. "You need to wait 6-8 weeks after each laser treatment so all the inflammation can resolve before the next treatment session" in order to avoid complications.

Dr. Sadick cautioned that the external 1064-nm Nd:YAG lasers are "sort of like weapons. They need to be handled very gently and understood, particularly when you’re treating the legs." Complications can include ulceration, purpura, blisters, and hyper- or hypopigmentation. These most commonly are caused by stacking pulses in a given area (especially with longer wavelengths), treating tanned skin, improperly matching wavelength to skin type, and failing to address hydrostatic pressure.

"If you use a short wavelength laser like a pulsed dye laser for a dark-skinned individual, for sure you’re going to get hypopigmentation and potential scarring," he said. Avoid laser treatment in patients who have larger vessels feeding the spider telangiectasia, because the hydrostatic pressure increases the risk for side effects.

The clinical goals of laser therapy for leg telangiectasia are to treat vasospasm, erythema, and urticaria. "It’s important to understand the end points of therapy. You don’t need to treat these veins until the vessels go away," he said.

Dr. Sadick has consulted for or received research grants from Cutera, Cynosure, Palomar, Solta Medical, and Syneron.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.