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Acid series: Azelaic acid
However, it has many positive qualities, including being gentle enough to use daily and is safe to use in pregnancy. It is antibacterial, comedolytic, keratolytic, and has antioxidant activity. Unfortunately, in the last decade the formulations of azelaic acid have not been changed considerably. The 20% cream, 15% gel, and 15% foam vehicles are often too irritating and drying to be used in the population it is intended for: those with rosacea, or with inflamed or sensitive skin.
Azelaic acid is a dicarboxylic acid produced by Pityrosporum ovale. It inhibits the synthesis of cellular proteins and is bactericidal against Propionibacterium acnes and Staphylococcus epidermidis. Azelaic acid is both keratolytic and comedolytic by decreasing keratohyalin granules and reducing filaggrin in the epidermis. It not only scavenges free oxygen radicals, thereby reducing inflammation, but is also a tyrosinase inhibitor – making it a safe, non–hydroquinone-based alternative to skin lightening.
Azelaic acid has little toxicity, it is ingested regularly as it is found in wheat, barley, and rye. Topical side effects are usually mild and can subside with increased use. The most common side effects include erythema, local stinging, pruritus, scaling, and a burning sensation. It is considered safe in pregnancy and a great alternative to medications for acne in pregnant or nursing patients.
The largest constraint with azelaic acid preparations on the market – and most likely the reason it has not been more widely used for acne, rosacea, antiaging, and hyperpigmentation – is the formulation. The foam and gel preparations are irritating and difficult to use on dry or sensitive skin. The 20% cream preparations are slightly better tolerated; however, in vitro skin-penetration studies have shown that cutaneous penetration of azelaic acid is greater after application of a 15% gel (aqueous-based vehicle) and 15% foam (hydrophilic oil-in-water emulsion) as compared with the 20% cream formulations.
In my clinical experience, azelaic acid can only be used in rosacea patients with oily or nonsensitive skin. The majority of my rosacea patients cannot tolerate the burning sensation, albeit transient and mild. Acne patients who do not have dry skin and pregnant patients with mild acne are a great population for integrating azelaic acid into an acne regimen. I also use azelaic acid as an alternative for mild melasma and lentigines in patients who are tapering off hydroquinone or cannot use hydroquinone. In the future, we need better, creamier, nonirritating formulations to be developed and more studies of higher concentrations of this acid for both prescription/patient at-home use, as well as more elegant in-office localized peel systems using azelaic acid.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Fitton A and Goa KL. Drugs. 1991 May;41(5):780-98.
Del Rosso JQ. J Clin Aesthet Dermatol. 2017 Mar;10(3):37-40.
Breathnach AC et al. Clin Dermatol. Apr-Jun 1989;7(2):106-19.
However, it has many positive qualities, including being gentle enough to use daily and is safe to use in pregnancy. It is antibacterial, comedolytic, keratolytic, and has antioxidant activity. Unfortunately, in the last decade the formulations of azelaic acid have not been changed considerably. The 20% cream, 15% gel, and 15% foam vehicles are often too irritating and drying to be used in the population it is intended for: those with rosacea, or with inflamed or sensitive skin.
Azelaic acid is a dicarboxylic acid produced by Pityrosporum ovale. It inhibits the synthesis of cellular proteins and is bactericidal against Propionibacterium acnes and Staphylococcus epidermidis. Azelaic acid is both keratolytic and comedolytic by decreasing keratohyalin granules and reducing filaggrin in the epidermis. It not only scavenges free oxygen radicals, thereby reducing inflammation, but is also a tyrosinase inhibitor – making it a safe, non–hydroquinone-based alternative to skin lightening.
Azelaic acid has little toxicity, it is ingested regularly as it is found in wheat, barley, and rye. Topical side effects are usually mild and can subside with increased use. The most common side effects include erythema, local stinging, pruritus, scaling, and a burning sensation. It is considered safe in pregnancy and a great alternative to medications for acne in pregnant or nursing patients.
The largest constraint with azelaic acid preparations on the market – and most likely the reason it has not been more widely used for acne, rosacea, antiaging, and hyperpigmentation – is the formulation. The foam and gel preparations are irritating and difficult to use on dry or sensitive skin. The 20% cream preparations are slightly better tolerated; however, in vitro skin-penetration studies have shown that cutaneous penetration of azelaic acid is greater after application of a 15% gel (aqueous-based vehicle) and 15% foam (hydrophilic oil-in-water emulsion) as compared with the 20% cream formulations.
In my clinical experience, azelaic acid can only be used in rosacea patients with oily or nonsensitive skin. The majority of my rosacea patients cannot tolerate the burning sensation, albeit transient and mild. Acne patients who do not have dry skin and pregnant patients with mild acne are a great population for integrating azelaic acid into an acne regimen. I also use azelaic acid as an alternative for mild melasma and lentigines in patients who are tapering off hydroquinone or cannot use hydroquinone. In the future, we need better, creamier, nonirritating formulations to be developed and more studies of higher concentrations of this acid for both prescription/patient at-home use, as well as more elegant in-office localized peel systems using azelaic acid.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Fitton A and Goa KL. Drugs. 1991 May;41(5):780-98.
Del Rosso JQ. J Clin Aesthet Dermatol. 2017 Mar;10(3):37-40.
Breathnach AC et al. Clin Dermatol. Apr-Jun 1989;7(2):106-19.
However, it has many positive qualities, including being gentle enough to use daily and is safe to use in pregnancy. It is antibacterial, comedolytic, keratolytic, and has antioxidant activity. Unfortunately, in the last decade the formulations of azelaic acid have not been changed considerably. The 20% cream, 15% gel, and 15% foam vehicles are often too irritating and drying to be used in the population it is intended for: those with rosacea, or with inflamed or sensitive skin.
Azelaic acid is a dicarboxylic acid produced by Pityrosporum ovale. It inhibits the synthesis of cellular proteins and is bactericidal against Propionibacterium acnes and Staphylococcus epidermidis. Azelaic acid is both keratolytic and comedolytic by decreasing keratohyalin granules and reducing filaggrin in the epidermis. It not only scavenges free oxygen radicals, thereby reducing inflammation, but is also a tyrosinase inhibitor – making it a safe, non–hydroquinone-based alternative to skin lightening.
Azelaic acid has little toxicity, it is ingested regularly as it is found in wheat, barley, and rye. Topical side effects are usually mild and can subside with increased use. The most common side effects include erythema, local stinging, pruritus, scaling, and a burning sensation. It is considered safe in pregnancy and a great alternative to medications for acne in pregnant or nursing patients.
The largest constraint with azelaic acid preparations on the market – and most likely the reason it has not been more widely used for acne, rosacea, antiaging, and hyperpigmentation – is the formulation. The foam and gel preparations are irritating and difficult to use on dry or sensitive skin. The 20% cream preparations are slightly better tolerated; however, in vitro skin-penetration studies have shown that cutaneous penetration of azelaic acid is greater after application of a 15% gel (aqueous-based vehicle) and 15% foam (hydrophilic oil-in-water emulsion) as compared with the 20% cream formulations.
In my clinical experience, azelaic acid can only be used in rosacea patients with oily or nonsensitive skin. The majority of my rosacea patients cannot tolerate the burning sensation, albeit transient and mild. Acne patients who do not have dry skin and pregnant patients with mild acne are a great population for integrating azelaic acid into an acne regimen. I also use azelaic acid as an alternative for mild melasma and lentigines in patients who are tapering off hydroquinone or cannot use hydroquinone. In the future, we need better, creamier, nonirritating formulations to be developed and more studies of higher concentrations of this acid for both prescription/patient at-home use, as well as more elegant in-office localized peel systems using azelaic acid.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
References
Fitton A and Goa KL. Drugs. 1991 May;41(5):780-98.
Del Rosso JQ. J Clin Aesthet Dermatol. 2017 Mar;10(3):37-40.
Breathnach AC et al. Clin Dermatol. Apr-Jun 1989;7(2):106-19.
Sea buckthorn: What is it and what is it good for?
To avoid jumping on the bandwagon of another ingredient trend, we sought to examine the scientific background and properties of sea buckthorn oil and it’s utility for the skin.
Sea buckthorn (Hippophae rhamnoides) – also known as a Siberian pineapple tree, and as sandthorn, sallowthorn, or seaberry – is a thorny, dioecious shrub (or tree) in the oleaster family. It can grow up to 23 feet high and is found in coastal sea cliff areas and on mountain slopes of Western Europe, and in dry sandy areas of Asia Minor and Central Asia, Siberia, China, and Tibet. Common sea buckthorn flowers in late April and early May, producing a large number of small, green and brown flowers, turning into edible, usually yellow or orange round berries. The berries have a bitter, sour taste and have a mild aroma, resembling that of a pineapple. The fruit contains a small stone that covers an oily seed.
The berries are a source of antioxidant vitamins, flavonoids, and organic acids, and when pressed, produce a juice that separates into three layers: a thick cream (upper layer), a combination of saturated and unsaturated fatty acids (middle layer), and juice that is a source of fat (lower layer). The berries contain mainly vitamin C, but also vitamin A (alpha- and beta-carotene) and a mixture of other carotenoids, as well as varying concentrations of tocopherols (vitamin E), folic acid, and vitamin B complex–group vitamins.
In addition to flavonoids, the berries contain catechins and procyanidins, cyclitols, phospholipids, tannins, sugars (galactose, fructose, xylose), organic acids (maleic acid, oxalic acid, malic acid, tartaric acid), phenolic acids (such as ferulic acid), and fatty oil. The amount of vitamin C content varies with the variety of the plant and where it is found. The oil of sea buckthorn may be extracted from two parts of the plant, with mechanical cold pressing of seeds (up to 12.5% weight as oil content) and fruit pulp (8%-12% oil content).
Among vegetable oils, sea buckthorn fruit oil has the highest content of palmitoleic acid (omega-7).
Fruit and seed oils contain tocotrienols and plant sterols. Pulp sea buckthorn oil has a high carotenoid content, as opposed to seed oil, and in Mongolia, Russia, and China, is used as a topical therapy for skin burns.
Other significant fatty acids found in sea buckthorn oil are saturated fatty acids (palmitic acid and stearic acid) and polyunsaturated fatty acids, which include alpha-linolenic acid (omega-3), gamma-linolenic acid (omega-6), linolic acid (omega-6), oleic acid (omega-9), and eicosanoic acid (omega-9). Gamma-linoleic acid in particular is reduced in dry skin conditions, such as aging and atopic dermatitis. The human body can produce some gamma-linolenic acid, oleic acid, and palmitoleic acid, but not linolic acid and alpha-linolenic acid. The addition of these substances to diet or skin care has been found to be beneficial in improving dryness and the skin barrier.
In addition, linolic acid, a natural component of human sebum, has been noted to be decreased in the sebum of people with acne-prone skin. Preliminary evidence indicates that dietary supplements containing fatty acids such as docosahexaenoic acid, sea buckthorn oil, and hemp seed oil may decrease the severity of atopic dermatitis.
Besides use in topical skin care and cosmetic preparations, sea buckthorn has also been used successfully in the treatment of chronic gastric ulcer disease, inflammation of the vagina and cervix, and cervical erosion. The bark and leaves of sea buckthorn used to be applied to treat diarrhea and dermatologic conditions, while berry oil has been applied topically or taken orally to soften the skin.
In traditional Indian, Chinese, and Tibetan medicines, sea buckthorn berries are used for medicinal purposes, as their ingredients were thought to have a beneficial effect on the function of the alimentary, respiratory, and circulatory systems. Current studies and uses are now confirming their utility experienced over hundreds of years.
Harvesting sea buckthorn fruit is difficult because of dense thorn arrangement among the berries. Therefore, sometimes the only way to obtain fruit is to remove the entire branch of the shrub, which reduces future crops. For this reason berries can only be harvested once every 2 years.
Sea buckthorn has interesting properties and could be of benefit in topical skin care, as long as it is not overharvested or harvested in a way that has a detrimental impact on the environment.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
United States Department of Agriculture. PLANTS Profile for Hippophae rhamnoides (seaberry). 2007.
Zielińska A and Nowak I. Lipids Health Dis. 2017 May 19;16(1):95.
Reynolds KA et al. Int J Dermatol. 2019 Dec;58(12):1371-6.
To avoid jumping on the bandwagon of another ingredient trend, we sought to examine the scientific background and properties of sea buckthorn oil and it’s utility for the skin.
Sea buckthorn (Hippophae rhamnoides) – also known as a Siberian pineapple tree, and as sandthorn, sallowthorn, or seaberry – is a thorny, dioecious shrub (or tree) in the oleaster family. It can grow up to 23 feet high and is found in coastal sea cliff areas and on mountain slopes of Western Europe, and in dry sandy areas of Asia Minor and Central Asia, Siberia, China, and Tibet. Common sea buckthorn flowers in late April and early May, producing a large number of small, green and brown flowers, turning into edible, usually yellow or orange round berries. The berries have a bitter, sour taste and have a mild aroma, resembling that of a pineapple. The fruit contains a small stone that covers an oily seed.
The berries are a source of antioxidant vitamins, flavonoids, and organic acids, and when pressed, produce a juice that separates into three layers: a thick cream (upper layer), a combination of saturated and unsaturated fatty acids (middle layer), and juice that is a source of fat (lower layer). The berries contain mainly vitamin C, but also vitamin A (alpha- and beta-carotene) and a mixture of other carotenoids, as well as varying concentrations of tocopherols (vitamin E), folic acid, and vitamin B complex–group vitamins.
In addition to flavonoids, the berries contain catechins and procyanidins, cyclitols, phospholipids, tannins, sugars (galactose, fructose, xylose), organic acids (maleic acid, oxalic acid, malic acid, tartaric acid), phenolic acids (such as ferulic acid), and fatty oil. The amount of vitamin C content varies with the variety of the plant and where it is found. The oil of sea buckthorn may be extracted from two parts of the plant, with mechanical cold pressing of seeds (up to 12.5% weight as oil content) and fruit pulp (8%-12% oil content).
Among vegetable oils, sea buckthorn fruit oil has the highest content of palmitoleic acid (omega-7).
Fruit and seed oils contain tocotrienols and plant sterols. Pulp sea buckthorn oil has a high carotenoid content, as opposed to seed oil, and in Mongolia, Russia, and China, is used as a topical therapy for skin burns.
Other significant fatty acids found in sea buckthorn oil are saturated fatty acids (palmitic acid and stearic acid) and polyunsaturated fatty acids, which include alpha-linolenic acid (omega-3), gamma-linolenic acid (omega-6), linolic acid (omega-6), oleic acid (omega-9), and eicosanoic acid (omega-9). Gamma-linoleic acid in particular is reduced in dry skin conditions, such as aging and atopic dermatitis. The human body can produce some gamma-linolenic acid, oleic acid, and palmitoleic acid, but not linolic acid and alpha-linolenic acid. The addition of these substances to diet or skin care has been found to be beneficial in improving dryness and the skin barrier.
In addition, linolic acid, a natural component of human sebum, has been noted to be decreased in the sebum of people with acne-prone skin. Preliminary evidence indicates that dietary supplements containing fatty acids such as docosahexaenoic acid, sea buckthorn oil, and hemp seed oil may decrease the severity of atopic dermatitis.
Besides use in topical skin care and cosmetic preparations, sea buckthorn has also been used successfully in the treatment of chronic gastric ulcer disease, inflammation of the vagina and cervix, and cervical erosion. The bark and leaves of sea buckthorn used to be applied to treat diarrhea and dermatologic conditions, while berry oil has been applied topically or taken orally to soften the skin.
In traditional Indian, Chinese, and Tibetan medicines, sea buckthorn berries are used for medicinal purposes, as their ingredients were thought to have a beneficial effect on the function of the alimentary, respiratory, and circulatory systems. Current studies and uses are now confirming their utility experienced over hundreds of years.
Harvesting sea buckthorn fruit is difficult because of dense thorn arrangement among the berries. Therefore, sometimes the only way to obtain fruit is to remove the entire branch of the shrub, which reduces future crops. For this reason berries can only be harvested once every 2 years.
Sea buckthorn has interesting properties and could be of benefit in topical skin care, as long as it is not overharvested or harvested in a way that has a detrimental impact on the environment.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
United States Department of Agriculture. PLANTS Profile for Hippophae rhamnoides (seaberry). 2007.
Zielińska A and Nowak I. Lipids Health Dis. 2017 May 19;16(1):95.
Reynolds KA et al. Int J Dermatol. 2019 Dec;58(12):1371-6.
To avoid jumping on the bandwagon of another ingredient trend, we sought to examine the scientific background and properties of sea buckthorn oil and it’s utility for the skin.
Sea buckthorn (Hippophae rhamnoides) – also known as a Siberian pineapple tree, and as sandthorn, sallowthorn, or seaberry – is a thorny, dioecious shrub (or tree) in the oleaster family. It can grow up to 23 feet high and is found in coastal sea cliff areas and on mountain slopes of Western Europe, and in dry sandy areas of Asia Minor and Central Asia, Siberia, China, and Tibet. Common sea buckthorn flowers in late April and early May, producing a large number of small, green and brown flowers, turning into edible, usually yellow or orange round berries. The berries have a bitter, sour taste and have a mild aroma, resembling that of a pineapple. The fruit contains a small stone that covers an oily seed.
The berries are a source of antioxidant vitamins, flavonoids, and organic acids, and when pressed, produce a juice that separates into three layers: a thick cream (upper layer), a combination of saturated and unsaturated fatty acids (middle layer), and juice that is a source of fat (lower layer). The berries contain mainly vitamin C, but also vitamin A (alpha- and beta-carotene) and a mixture of other carotenoids, as well as varying concentrations of tocopherols (vitamin E), folic acid, and vitamin B complex–group vitamins.
In addition to flavonoids, the berries contain catechins and procyanidins, cyclitols, phospholipids, tannins, sugars (galactose, fructose, xylose), organic acids (maleic acid, oxalic acid, malic acid, tartaric acid), phenolic acids (such as ferulic acid), and fatty oil. The amount of vitamin C content varies with the variety of the plant and where it is found. The oil of sea buckthorn may be extracted from two parts of the plant, with mechanical cold pressing of seeds (up to 12.5% weight as oil content) and fruit pulp (8%-12% oil content).
Among vegetable oils, sea buckthorn fruit oil has the highest content of palmitoleic acid (omega-7).
Fruit and seed oils contain tocotrienols and plant sterols. Pulp sea buckthorn oil has a high carotenoid content, as opposed to seed oil, and in Mongolia, Russia, and China, is used as a topical therapy for skin burns.
Other significant fatty acids found in sea buckthorn oil are saturated fatty acids (palmitic acid and stearic acid) and polyunsaturated fatty acids, which include alpha-linolenic acid (omega-3), gamma-linolenic acid (omega-6), linolic acid (omega-6), oleic acid (omega-9), and eicosanoic acid (omega-9). Gamma-linoleic acid in particular is reduced in dry skin conditions, such as aging and atopic dermatitis. The human body can produce some gamma-linolenic acid, oleic acid, and palmitoleic acid, but not linolic acid and alpha-linolenic acid. The addition of these substances to diet or skin care has been found to be beneficial in improving dryness and the skin barrier.
In addition, linolic acid, a natural component of human sebum, has been noted to be decreased in the sebum of people with acne-prone skin. Preliminary evidence indicates that dietary supplements containing fatty acids such as docosahexaenoic acid, sea buckthorn oil, and hemp seed oil may decrease the severity of atopic dermatitis.
Besides use in topical skin care and cosmetic preparations, sea buckthorn has also been used successfully in the treatment of chronic gastric ulcer disease, inflammation of the vagina and cervix, and cervical erosion. The bark and leaves of sea buckthorn used to be applied to treat diarrhea and dermatologic conditions, while berry oil has been applied topically or taken orally to soften the skin.
In traditional Indian, Chinese, and Tibetan medicines, sea buckthorn berries are used for medicinal purposes, as their ingredients were thought to have a beneficial effect on the function of the alimentary, respiratory, and circulatory systems. Current studies and uses are now confirming their utility experienced over hundreds of years.
Harvesting sea buckthorn fruit is difficult because of dense thorn arrangement among the berries. Therefore, sometimes the only way to obtain fruit is to remove the entire branch of the shrub, which reduces future crops. For this reason berries can only be harvested once every 2 years.
Sea buckthorn has interesting properties and could be of benefit in topical skin care, as long as it is not overharvested or harvested in a way that has a detrimental impact on the environment.
Dr. Wesley and Lily Talakoub, MD, are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
United States Department of Agriculture. PLANTS Profile for Hippophae rhamnoides (seaberry). 2007.
Zielińska A and Nowak I. Lipids Health Dis. 2017 May 19;16(1):95.
Reynolds KA et al. Int J Dermatol. 2019 Dec;58(12):1371-6.
Acid series: Lactic acid
One of the most commonly used organic acids used on the skin, lactic acid, has been used for over 3 decades. Originally derived from milk or plant-derived sugars, this gentle exfoliating acid can be used in peels, serums, masks, and toners, and has the additional benefit of hydrating the skin. Lactic acid is formulated in concentrations from 2% to 50%; however, because of its large molecular size, it doesn’t penetrate the deeper layers of the dermis to the same extent as the other alpha-hydroxy acids (AHAs), such as glycolic acid. Thus, it is one of the gentler exfoliants and one that can be used in sensitive skin or darker skin types.
Despite its mild peeling effects, lactic acid is best used to treat xerotic skin because of its function as a humectant, drawing moisture into the stratum corneum. Similar to the other AHAs, lactic acid has also been shown to decrease melanogenesis and is a gentle treatment for skin hyperpigmentation, particularly in skin of color. Side effects include peeling, stinging, erythema, photosensitivity, and hyperpigmentation when improperly used.
Very little clinical research has been reported in the last 20 years as to the uses and benefits of lactic acid in skincare. In my clinical experience, daily use of lactic acid is more effective and has more long-term benefits for hydration and rejuvenation of the skin than the other AHAs. Concentrations of 10%-15% used daily on the skin as a mild exfoliant and humectant have shown to improve texture, decrease pigmentation and improve fine lines – without thinning of the skin seen with the deeper dermal penetrating acids.
Confusion in the market has also risen as many over-the-counter brands have included ammonium lactate in their portfolio of moisturizers. Ammonium lactate is a combination of ammonium hydroxide and lactic acid, or the salt of lactic acid. A comparative study evaluating the difference between 5% lactic acid and 12% ammonium lactate for the treatment of xerosis showed that ammonium lactate was significantly more effective at reducing xerosis. It is widely used in the treatment of keratosis pilaris, calluses, xerosis, and ichthyosis.
Widespread use of lactic acid has not gotten as much glory as that of glycolic acid. However, in clinical practice, its functions are more widespread. It is a much safer acid to use, and its added benefit of increasing hydration of the skin is crucial in its long-term use for both photoaging and the prevention of wrinkles. With any acid, the exfoliating properties must be treated with adequate hydration and barrier repair.
The intrinsic moisturizing effect of lactic acid makes it a much more well-rounded acid and that can be used for longer periods of time in a broader spectrum of patients.
Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
One of the most commonly used organic acids used on the skin, lactic acid, has been used for over 3 decades. Originally derived from milk or plant-derived sugars, this gentle exfoliating acid can be used in peels, serums, masks, and toners, and has the additional benefit of hydrating the skin. Lactic acid is formulated in concentrations from 2% to 50%; however, because of its large molecular size, it doesn’t penetrate the deeper layers of the dermis to the same extent as the other alpha-hydroxy acids (AHAs), such as glycolic acid. Thus, it is one of the gentler exfoliants and one that can be used in sensitive skin or darker skin types.
Despite its mild peeling effects, lactic acid is best used to treat xerotic skin because of its function as a humectant, drawing moisture into the stratum corneum. Similar to the other AHAs, lactic acid has also been shown to decrease melanogenesis and is a gentle treatment for skin hyperpigmentation, particularly in skin of color. Side effects include peeling, stinging, erythema, photosensitivity, and hyperpigmentation when improperly used.
Very little clinical research has been reported in the last 20 years as to the uses and benefits of lactic acid in skincare. In my clinical experience, daily use of lactic acid is more effective and has more long-term benefits for hydration and rejuvenation of the skin than the other AHAs. Concentrations of 10%-15% used daily on the skin as a mild exfoliant and humectant have shown to improve texture, decrease pigmentation and improve fine lines – without thinning of the skin seen with the deeper dermal penetrating acids.
Confusion in the market has also risen as many over-the-counter brands have included ammonium lactate in their portfolio of moisturizers. Ammonium lactate is a combination of ammonium hydroxide and lactic acid, or the salt of lactic acid. A comparative study evaluating the difference between 5% lactic acid and 12% ammonium lactate for the treatment of xerosis showed that ammonium lactate was significantly more effective at reducing xerosis. It is widely used in the treatment of keratosis pilaris, calluses, xerosis, and ichthyosis.
Widespread use of lactic acid has not gotten as much glory as that of glycolic acid. However, in clinical practice, its functions are more widespread. It is a much safer acid to use, and its added benefit of increasing hydration of the skin is crucial in its long-term use for both photoaging and the prevention of wrinkles. With any acid, the exfoliating properties must be treated with adequate hydration and barrier repair.
The intrinsic moisturizing effect of lactic acid makes it a much more well-rounded acid and that can be used for longer periods of time in a broader spectrum of patients.
Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
One of the most commonly used organic acids used on the skin, lactic acid, has been used for over 3 decades. Originally derived from milk or plant-derived sugars, this gentle exfoliating acid can be used in peels, serums, masks, and toners, and has the additional benefit of hydrating the skin. Lactic acid is formulated in concentrations from 2% to 50%; however, because of its large molecular size, it doesn’t penetrate the deeper layers of the dermis to the same extent as the other alpha-hydroxy acids (AHAs), such as glycolic acid. Thus, it is one of the gentler exfoliants and one that can be used in sensitive skin or darker skin types.
Despite its mild peeling effects, lactic acid is best used to treat xerotic skin because of its function as a humectant, drawing moisture into the stratum corneum. Similar to the other AHAs, lactic acid has also been shown to decrease melanogenesis and is a gentle treatment for skin hyperpigmentation, particularly in skin of color. Side effects include peeling, stinging, erythema, photosensitivity, and hyperpigmentation when improperly used.
Very little clinical research has been reported in the last 20 years as to the uses and benefits of lactic acid in skincare. In my clinical experience, daily use of lactic acid is more effective and has more long-term benefits for hydration and rejuvenation of the skin than the other AHAs. Concentrations of 10%-15% used daily on the skin as a mild exfoliant and humectant have shown to improve texture, decrease pigmentation and improve fine lines – without thinning of the skin seen with the deeper dermal penetrating acids.
Confusion in the market has also risen as many over-the-counter brands have included ammonium lactate in their portfolio of moisturizers. Ammonium lactate is a combination of ammonium hydroxide and lactic acid, or the salt of lactic acid. A comparative study evaluating the difference between 5% lactic acid and 12% ammonium lactate for the treatment of xerosis showed that ammonium lactate was significantly more effective at reducing xerosis. It is widely used in the treatment of keratosis pilaris, calluses, xerosis, and ichthyosis.
Widespread use of lactic acid has not gotten as much glory as that of glycolic acid. However, in clinical practice, its functions are more widespread. It is a much safer acid to use, and its added benefit of increasing hydration of the skin is crucial in its long-term use for both photoaging and the prevention of wrinkles. With any acid, the exfoliating properties must be treated with adequate hydration and barrier repair.
The intrinsic moisturizing effect of lactic acid makes it a much more well-rounded acid and that can be used for longer periods of time in a broader spectrum of patients.
Dr. Lily Talakoub and Dr. Naissan O. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
Graying of hair: Could it be reversed?
as hair pigment goes through its natural progression of senescence.
However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.
In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.
When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.
Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.
Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.
The study was supported by the Wharton Fund and grants from the National Institutes of Health.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.
as hair pigment goes through its natural progression of senescence.
However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.
In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.
When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.
Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.
Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.
The study was supported by the Wharton Fund and grants from the National Institutes of Health.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.
as hair pigment goes through its natural progression of senescence.
However, the recent publication that is a collaboration between the department of psychiatry at Columbia University, New York; and the departments of dermatology at the University College Dublin, University of Miami, and the University of Manchester (England); and the Monasterium Laboratory in Münster, Germany, demonstrates a quantitative mapping of human hair graying – and its reversal – in relation to stress.
In the study, hair color of single strands of hair from seven healthy females and seven healthy males, whose mean age was 35 years (range, 9-65 years), were analyzed. In addition to hair pigment analysis, study subjects documented the stress they were experiencing each week in diaries. Using either high resolution image scanners, electron microscopy, and/or hair shaft proteomics, the investigators were able to evaluate loss of pigment within fragments small enough to have grown over one hour.
When changes in hair color were noted, variations in up to 300 proteins were documented, including an up-regulation of the fatty acid synthesis and metabolism machinery in graying. Recent studies also corroborate that fatty acid synthesis by fatty acid synthase and “transport by CPT1A ... are sufficient drivers of cell senescence, and that fatty acid metabolism regulates melanocyte aging biology” the authors wrote.
Molecularly, the investigators found that gray hairs up-regulate proteins associated with energy metabolism, mitochondria, and antioxidant defenses. The graying correlated with stress was also reversible, “at least temporarily,” based on their retrospective analysis and analysis over the 2.5-year recruitment period, the investigators wrote. Specifically, they found that graying hair “may be acutely triggered by stressful life experiences, the removal of which can trigger reversal.” From the data, they also developed a mathematical model to predict what might happen to human hair over time.
Through this study, proof-of-concept evidence is provided indicating that biobehavioral factors are linked to human hair graying dynamics. Future analysis with larger sample sizes and incorporating neuroendocrine markers may further support these correlations. This is an interesting study that elucidates the mechanisms responsible for how stress and other life exposures manifest in human biology, and, if we as human beings effectively manage that stress, how it may both reverse the negative impact and outcomes affecting our body and health.
The study was supported by the Wharton Fund and grants from the National Institutes of Health.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They have no relevant disclosures.
Understanding the alpha hydroxy acids: Glycolic acid
. The extent of exfoliation with any of the alpha hydroxy acids depends on the type of acid, its concentration, and the pH of the preparations. Glycolic acid inhibits tyrosinase and chelates calcium ion concentration between the cells in the epidermis, which results in exfoliation of the skin.
Over-the-counter glycolic acid is available in concentrations up to 30%, and in professional products up to 70%. Clinically, glycolic acid above a concentration of 30% causes local burning, erythema, and dryness.
However, overuse of glycolic acid among consumers has increased the incidence of skin reactions and hyperpigmentation. Professional-grade products containing up to 70% glycolic acid are widely available on the Internet and without proper guidelines on use and sun avoidance, adverse events and long term scarring are becoming prevalent.
The overuse of acids and overexfoliation of the skin in patients with skin types I-IV is a growing problem as consumers are purchasing more “at-home peels,” peel pads, glow pads, and at-home exfoliation regimens. This overexfoliation of the skin and the resulting erythema induces rapid postinflammatory hyperpigmentation. Consumers then often mistakenly try to self-treat the hyperpigmentation with increasing concentrations of acids, retinols, and/or hydroquinone on top of an already compromised skin barrier, further worsening the problem. In addition, these acids increase sensitivity to UV light and increase the risk of sunburns in all skin types.
Although glycolic acids are generally safe, standardized recommendations for their use in the skin care market are necessary. More is not always better. In our clinic, we do not treat patients with postinflammatory hyperpigmentation from acids or peels with more exfoliation. We focus on repairing the barrier for 1-3 months, which includes use of gentle cleansers and occlusive moisturizers, and avoidance of acids, retinols, or scrubs, and aggressive sun protection, and then using gentle fade ingredients – such as kojic acid, licorice root extract, and vitamin C – at low concentrations to slowly decrease melanin production. Barrier repair is the first and most important step and it is often overlooked when clinicians try to lighten the skin in haste.
Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
. The extent of exfoliation with any of the alpha hydroxy acids depends on the type of acid, its concentration, and the pH of the preparations. Glycolic acid inhibits tyrosinase and chelates calcium ion concentration between the cells in the epidermis, which results in exfoliation of the skin.
Over-the-counter glycolic acid is available in concentrations up to 30%, and in professional products up to 70%. Clinically, glycolic acid above a concentration of 30% causes local burning, erythema, and dryness.
However, overuse of glycolic acid among consumers has increased the incidence of skin reactions and hyperpigmentation. Professional-grade products containing up to 70% glycolic acid are widely available on the Internet and without proper guidelines on use and sun avoidance, adverse events and long term scarring are becoming prevalent.
The overuse of acids and overexfoliation of the skin in patients with skin types I-IV is a growing problem as consumers are purchasing more “at-home peels,” peel pads, glow pads, and at-home exfoliation regimens. This overexfoliation of the skin and the resulting erythema induces rapid postinflammatory hyperpigmentation. Consumers then often mistakenly try to self-treat the hyperpigmentation with increasing concentrations of acids, retinols, and/or hydroquinone on top of an already compromised skin barrier, further worsening the problem. In addition, these acids increase sensitivity to UV light and increase the risk of sunburns in all skin types.
Although glycolic acids are generally safe, standardized recommendations for their use in the skin care market are necessary. More is not always better. In our clinic, we do not treat patients with postinflammatory hyperpigmentation from acids or peels with more exfoliation. We focus on repairing the barrier for 1-3 months, which includes use of gentle cleansers and occlusive moisturizers, and avoidance of acids, retinols, or scrubs, and aggressive sun protection, and then using gentle fade ingredients – such as kojic acid, licorice root extract, and vitamin C – at low concentrations to slowly decrease melanin production. Barrier repair is the first and most important step and it is often overlooked when clinicians try to lighten the skin in haste.
Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
. The extent of exfoliation with any of the alpha hydroxy acids depends on the type of acid, its concentration, and the pH of the preparations. Glycolic acid inhibits tyrosinase and chelates calcium ion concentration between the cells in the epidermis, which results in exfoliation of the skin.
Over-the-counter glycolic acid is available in concentrations up to 30%, and in professional products up to 70%. Clinically, glycolic acid above a concentration of 30% causes local burning, erythema, and dryness.
However, overuse of glycolic acid among consumers has increased the incidence of skin reactions and hyperpigmentation. Professional-grade products containing up to 70% glycolic acid are widely available on the Internet and without proper guidelines on use and sun avoidance, adverse events and long term scarring are becoming prevalent.
The overuse of acids and overexfoliation of the skin in patients with skin types I-IV is a growing problem as consumers are purchasing more “at-home peels,” peel pads, glow pads, and at-home exfoliation regimens. This overexfoliation of the skin and the resulting erythema induces rapid postinflammatory hyperpigmentation. Consumers then often mistakenly try to self-treat the hyperpigmentation with increasing concentrations of acids, retinols, and/or hydroquinone on top of an already compromised skin barrier, further worsening the problem. In addition, these acids increase sensitivity to UV light and increase the risk of sunburns in all skin types.
Although glycolic acids are generally safe, standardized recommendations for their use in the skin care market are necessary. More is not always better. In our clinic, we do not treat patients with postinflammatory hyperpigmentation from acids or peels with more exfoliation. We focus on repairing the barrier for 1-3 months, which includes use of gentle cleansers and occlusive moisturizers, and avoidance of acids, retinols, or scrubs, and aggressive sun protection, and then using gentle fade ingredients – such as kojic acid, licorice root extract, and vitamin C – at low concentrations to slowly decrease melanin production. Barrier repair is the first and most important step and it is often overlooked when clinicians try to lighten the skin in haste.
Dr. Lily Talakoub and Dr. Naissan O. Wesley and are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. They had no relevant disclosures. Write to them at [email protected].
Botulinum toxin and depression
. But confounding factors, such as medications, injection/acupuncture effect, physician interaction or touch, or other life scenarios, have made it difficult to discern botulinum toxin type A’s true effect on mood or psychiatric diagnosis. Now a systematic review and meta-analysis of randomized controlled trials examining botulinum toxin versus placebo provides evidence that botulinum toxin type A (BTX-A) injections are associated with statistically significant improvement in depressive symptoms.
Qian et al. analyzed all randomized controlled trials that investigated the efficacy and safety of facial BTX-A injections on patients with a diagnosis of major depressive disorder in PubMed and Web of Science from inception to June 17, 2020. A meta-analysis of the changes in depressive symptoms 6 weeks after BTX-A injections compared with placebo were the primary outcome of the report, while the safety of injections were also assessed.
A total of 417 patients from five randomized controlled trials (189 patients who received BTX-A injections and 228 in the placebo group) were deemed eligible. There was a statistically significant improvement in depressive symptoms in the BTX-A injections compared with placebo (Hedges’ g, –0.82; 95% confidence interval, –1.38 to 0.27). BTX-A injections were well tolerated with mild and temporary adverse events (headache, eyelid ptosis, and upper respiratory tract infection) reported in three of the five studies.
Limitations to the analysis include publication bias due to the limited number of studies in the analysis, the difficulty of being able to reliably blind participants because of potential noticeable cosmetic effects of BTX-A treatment, and the heterogeneity of symptom severity associated with major depressive disorder.
The authors referred to the Global Burden of Disease Study, which estimated that approximately 216 million people experienced major depressive disorder in 2015, the latest data available. MDD symptoms of sadness, fatigue, and loss of interest or pleasure, “incur a tremendous burden on health and finances,” they wrote. According to the Department of Health and Human Services, it is estimated that about 60% of people who commit suicide have had a mood disorder (major depression, bipolar disorder, dysthymia). The high rate of suicide associated with severe depression is also a serious public health concern. While further analysis is clearly warranted, cosmetic BTX-A injections may provide an alternative option in the treatment of depression.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. They had no relevant disclosures.
. But confounding factors, such as medications, injection/acupuncture effect, physician interaction or touch, or other life scenarios, have made it difficult to discern botulinum toxin type A’s true effect on mood or psychiatric diagnosis. Now a systematic review and meta-analysis of randomized controlled trials examining botulinum toxin versus placebo provides evidence that botulinum toxin type A (BTX-A) injections are associated with statistically significant improvement in depressive symptoms.
Qian et al. analyzed all randomized controlled trials that investigated the efficacy and safety of facial BTX-A injections on patients with a diagnosis of major depressive disorder in PubMed and Web of Science from inception to June 17, 2020. A meta-analysis of the changes in depressive symptoms 6 weeks after BTX-A injections compared with placebo were the primary outcome of the report, while the safety of injections were also assessed.
A total of 417 patients from five randomized controlled trials (189 patients who received BTX-A injections and 228 in the placebo group) were deemed eligible. There was a statistically significant improvement in depressive symptoms in the BTX-A injections compared with placebo (Hedges’ g, –0.82; 95% confidence interval, –1.38 to 0.27). BTX-A injections were well tolerated with mild and temporary adverse events (headache, eyelid ptosis, and upper respiratory tract infection) reported in three of the five studies.
Limitations to the analysis include publication bias due to the limited number of studies in the analysis, the difficulty of being able to reliably blind participants because of potential noticeable cosmetic effects of BTX-A treatment, and the heterogeneity of symptom severity associated with major depressive disorder.
The authors referred to the Global Burden of Disease Study, which estimated that approximately 216 million people experienced major depressive disorder in 2015, the latest data available. MDD symptoms of sadness, fatigue, and loss of interest or pleasure, “incur a tremendous burden on health and finances,” they wrote. According to the Department of Health and Human Services, it is estimated that about 60% of people who commit suicide have had a mood disorder (major depression, bipolar disorder, dysthymia). The high rate of suicide associated with severe depression is also a serious public health concern. While further analysis is clearly warranted, cosmetic BTX-A injections may provide an alternative option in the treatment of depression.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. They had no relevant disclosures.
. But confounding factors, such as medications, injection/acupuncture effect, physician interaction or touch, or other life scenarios, have made it difficult to discern botulinum toxin type A’s true effect on mood or psychiatric diagnosis. Now a systematic review and meta-analysis of randomized controlled trials examining botulinum toxin versus placebo provides evidence that botulinum toxin type A (BTX-A) injections are associated with statistically significant improvement in depressive symptoms.
Qian et al. analyzed all randomized controlled trials that investigated the efficacy and safety of facial BTX-A injections on patients with a diagnosis of major depressive disorder in PubMed and Web of Science from inception to June 17, 2020. A meta-analysis of the changes in depressive symptoms 6 weeks after BTX-A injections compared with placebo were the primary outcome of the report, while the safety of injections were also assessed.
A total of 417 patients from five randomized controlled trials (189 patients who received BTX-A injections and 228 in the placebo group) were deemed eligible. There was a statistically significant improvement in depressive symptoms in the BTX-A injections compared with placebo (Hedges’ g, –0.82; 95% confidence interval, –1.38 to 0.27). BTX-A injections were well tolerated with mild and temporary adverse events (headache, eyelid ptosis, and upper respiratory tract infection) reported in three of the five studies.
Limitations to the analysis include publication bias due to the limited number of studies in the analysis, the difficulty of being able to reliably blind participants because of potential noticeable cosmetic effects of BTX-A treatment, and the heterogeneity of symptom severity associated with major depressive disorder.
The authors referred to the Global Burden of Disease Study, which estimated that approximately 216 million people experienced major depressive disorder in 2015, the latest data available. MDD symptoms of sadness, fatigue, and loss of interest or pleasure, “incur a tremendous burden on health and finances,” they wrote. According to the Department of Health and Human Services, it is estimated that about 60% of people who commit suicide have had a mood disorder (major depression, bipolar disorder, dysthymia). The high rate of suicide associated with severe depression is also a serious public health concern. While further analysis is clearly warranted, cosmetic BTX-A injections may provide an alternative option in the treatment of depression.
Dr. Wesley and Dr. Lily Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. Write to them at [email protected]. They had no relevant disclosures.
The Zoom effect on cosmetic procedures
As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. .
While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
The Zoom effect
One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.
Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.
Since photography is a hobby, I counsel patients that lighting and shadows play a huge role in how they appear on screen. Depending on the lighting, camera angle, and camera quality, suboptimal lighting can highlight shadows and wrinkles not normally seen in natural or optimal light. In a recent interview on KCRW, the Los Angeles NPR affiliate station, the founding director of the Virtual Human Interaction Lab (VHIL) at Stanford University highlighted work on the effect that Zoom and virtual interactions have had on people during the COVID-19 pandemic. He notes that during a normal in-person meeting or conference, attention is usually on the person speaking, but now with everyone on camera at once, people have the pressure and subsequent feelings of exhaustion (a different type of exhaustion than being there in person) of being seen at all times. To address “Zoom Fatigue,” the VHIL’s recommendations include turning off the camera periodically, or changing the settings so your image is not seen. Another option is to use background filters, including some face filters (a cat for example), which Zoom has created to ease some of the stress of these meetings.
Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.
The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.
While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. .
While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
The Zoom effect
One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.
Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.
Since photography is a hobby, I counsel patients that lighting and shadows play a huge role in how they appear on screen. Depending on the lighting, camera angle, and camera quality, suboptimal lighting can highlight shadows and wrinkles not normally seen in natural or optimal light. In a recent interview on KCRW, the Los Angeles NPR affiliate station, the founding director of the Virtual Human Interaction Lab (VHIL) at Stanford University highlighted work on the effect that Zoom and virtual interactions have had on people during the COVID-19 pandemic. He notes that during a normal in-person meeting or conference, attention is usually on the person speaking, but now with everyone on camera at once, people have the pressure and subsequent feelings of exhaustion (a different type of exhaustion than being there in person) of being seen at all times. To address “Zoom Fatigue,” the VHIL’s recommendations include turning off the camera periodically, or changing the settings so your image is not seen. Another option is to use background filters, including some face filters (a cat for example), which Zoom has created to ease some of the stress of these meetings.
Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.
The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.
While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
As clinics were allowed to reopen under local government guidelines several months into the COVID-19 pandemic, many cosmetic dermatologists and aesthetic surgeons had no idea what our schedules would be like. .
While scheduled appointments, no shows, cancellations, and rebookings seem to wax and wane with surges in COVID-19 cases locally and with associated media coverage, there appear to be several reasons why demand has increased. Because people are wearing masks, they can easily hide signs of recovery or “something new” in their appearance. Patients aren’t typically around as many people and have more time to recover in private. There is also the positive effect a procedure can have on mood and self-esteem during what has been a difficult year. And people have had more time to read beauty and self-care articles, as well as advertisements for skin and hair care on social media.
The Zoom effect
One reason I did not anticipate is the Zoom effect. I don’t intend to single out Zoom – as there are other videoconferencing options available – but it seems to be the one patients bring up the most. Virtual meetings, conferences, and social events, and video calls with loved ones have become a part of daily routines for many, who are now seeing themselves on camera during these interactions as they never did before. It has created a strange new phenomenon.
Patients have literally said to me “I don’t like the way I look on Zoom” and ask about options to improve what they are seeing. They are often surprised to see that their appearance on virtual meetings, for example, does not reflect the way they feel inside, or how they think they should look. Even medical dermatology patients who have had no interest in cosmetic procedures previously have been coming in for this specific reason – both female and male patients.
Since photography is a hobby, I counsel patients that lighting and shadows play a huge role in how they appear on screen. Depending on the lighting, camera angle, and camera quality, suboptimal lighting can highlight shadows and wrinkles not normally seen in natural or optimal light. In a recent interview on KCRW, the Los Angeles NPR affiliate station, the founding director of the Virtual Human Interaction Lab (VHIL) at Stanford University highlighted work on the effect that Zoom and virtual interactions have had on people during the COVID-19 pandemic. He notes that during a normal in-person meeting or conference, attention is usually on the person speaking, but now with everyone on camera at once, people have the pressure and subsequent feelings of exhaustion (a different type of exhaustion than being there in person) of being seen at all times. To address “Zoom Fatigue,” the VHIL’s recommendations include turning off the camera periodically, or changing the settings so your image is not seen. Another option is to use background filters, including some face filters (a cat for example), which Zoom has created to ease some of the stress of these meetings.
Back to the actual in-person office visits: In my experience, all cosmetic procedures across the board, including injectables, skin resurfacing, and lasers have increased. In Dr. Talakoub’s practice, she has noted a tenfold increase in the use of deoxycholic acid (Kybella) and neck procedures attributed to the unflattering angle of the neck as people look down on their computer screens.There has also been an increase in the use of other injectables, such as Botox of the glabella to address scowling at the screen, facial fillers to address the dark shadows cast on the tear troughs, and lip fillers (noted to be 10-20 times higher) because of masks that can hide healing downtime. Similarly, increased use of Coolsculpting has been noted, as some patients have the flexibility of being able to take their Zoom meetings during the procedure, when they otherwise may not have had the time. Some patients have told me that the appointment with me is the only visit they’ve made outside of their home during the pandemic. Once the consultations or procedures are completed, patients often show gratitude and their self-esteem is increased. Some patients have said they even feel better and more productive at work, or note more positive interactions with their loved ones after the work has been done, likely because they feel better about themselves.There have been discussions about the benefits people have in being able to use Zoom and other videoconferencing platforms to gather and create, as well as see people and communicate in a way that can sometimes be more effective than a phone call. As physicians, these virtual tools have also allowed us to provide telehealth visits, a flexible, safe, and comfortable option for both the patient and practitioner. If done in a safe place, the ability to see each other without wearing a mask is also a nice treat.
The gratification and improvement in psyche that patients experience after our visits during this unprecedented, challenging time has been evident. Perhaps it’s the social interaction with their trusted physician, the outcome of the procedure itself, or a combination of both, which has a net positive effect on the physician-patient relationship.
While cosmetic procedures are appropriately deemed elective by hospital facilities and practitioners and should be of lower importance with regard to use of available facilities and PPE than those related to COVID-19 and other life-threatening scenarios, the longevity of this pandemic has surprisingly highlighted the numerous ways in which cosmetic visits can help patients, and the importance of being able to be there for patients – in a safe manner for all involved.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
Treatment of horizontal neck lines
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
The interplay of the neck subunits, as outlined in the recent article by Friedman and colleagues, requires multiple combination treatments, including fat removal, augmentation of deficient bony prominences, relaxation of hyperkinetic muscles, tissue tightening, suture anchoring, skin resurfacing, and treatment of dyschromia.
Horizontal neck lines are linear etched lines or furrows that commonly appear at a young age and are not caused by the aging process. The anatomy of the neck and the manner in which it bends contributes to their development at an early age. It is hypothesized that variable adipose tissue thickness and fibromuscular bands contribute to deepening of these lines in overweight patients. The widespread use of cell phones, laptops, and tablets has increased their prevalence and this has become one of the most common concerns of patients aged under 30 years in my clinic.
Various treatments have been recommended for neck rejuvenation, including hyaluronic acid and dilute calcium hydroxylapatite. In my experience, neither of these treatments adequately resolves the horizontal neck lines, and more importantly, prevents them from reoccurring. In addition, given the variability in skin and adipose thickness in the anterior neck, side effects including lumps, irregular correction, and the Tyndall effect, are common, particularly with incorrect choice of filler and injection depth.
The fibromuscular bands along the transverse neck lines pose one of the complexities in treatment with injectable filler. I have had significant improvement in the aesthetic outcome of my patients by using subcision along the transverse bands extensively prior to injection with hyaluronic acid fillers. The subcision is done with a 27-gauge needle to release the fibrous bands that tether the tissue down. If a patient has excess adipose tissue on either side of the bands, injectable fillers often do not improve the appearance of the lines and can make the neck appear heavier. The use of subcision followed by one to six treatments of deoxycholic acid in the adjacent adipose tissue prior to injection with a filler will help even out the contour of the neck, decrease adipose tissue bulges, release the fibrous bands, and fill the lines properly.
Working from home and on handheld devices has increased the appearance of neck lines in young populations. Despite the vast array of treatments in the aging neck, none have been very successful for this particular problem in the young. We need an improved understanding of these lines and better studies to investigate treatment options and long-term correction.
References:
Friedman O et al. J Cosmet Dermatol. 2021 Feb;20(2):569-76.
Brandt FS and Boker A. Dermatol Clin. 2004 Apr;22(2):159-66.
Tseng F and Yu H. Plast Reconstr Surg Glob Open. 2019 Aug 19;7(8):e2366.
Dibernardo BE. J Cosmet Laser Ther. 2013 Apr;15(2):56-64.
Jones D et al. Dermatol Surg. 2016 Oct;4 Suppl 1(Suppl 1):S235-42.
Lee SK and Kim HS. J Cosmet Dermatol. 2018 Aug;17(4):590-5.
Chao YY et al. Dermatol Surg. 2011 Oct;37(10):1542-5.
Han TY et al. Dermatol Surg. 2011 Sep;37(9):1291-6.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
Topical tranexamic acid for melasma
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
By addressing the vascular component of melasma, off-label use of oral tranexamic acid has been a beneficial adjunct for this difficult-to-treat condition. For on-label use treating menorrhagia (the oral form) and short-term prophylaxis of bleeding in hemophilia patients undergoing dental procedures – (the injectable form), tranexamic acid acts as an antifibrinolytic.
By inhibiting plasminogen activation, according to a 2018 review article “tranexamic acid mitigates UV radiation–induced melanogenesis and neovascularization,” both exhibited in the clinical manifestations of melasma.1 In addition to inhibiting fibrinolysis, tranexamic acid has direct effects on UV-induced pigmentation, “via its inhibitory effects on UV light–induced plasminogen activator on keratinocytes and [subsequent] plasmin activity,” the article states. “Plasminogen activator induces tyrosinase activity, resulting in increased melanin synthesis. The presence of plasmin [which dissolves clots by degrading fibrin] results in increased production of both arachidonic acid and fibroblast growth factor, which stimulate melanogenesis and neovascularization, respectively.”
With oral use, the risk of clot formation, especially in those who have a history of blood clots, clotting disorders (such as factor V Leiden), smoking, or other hypercoagulability risks should be weighed.
Topical tranexamic acid used locally mitigates systemic risk, and according to published studies, has been found to be efficacious for hemostasis in knee and hip arthroplasty surgery and for epistaxis. However, clinical outcomes with the topical treatment have largely not been on par with regards to efficacy for melasma when compared with oral tranexamic acid.
. Topical tranexamic acid, in my experience, when applied immediately after fractional 1927-nm diode laser treatment, not only has been noted by patients to feel soothing, but anecdotally has been found to improve pigmentation.
Moreover, there are now several peer-reviewed studies showing some benefit for treating pigmentation from photodamage or melasma with laser-assisted delivery of topical tranexamic acid. Treatment of these conditions may also benefit from nonablative 1927-nm laser alone.
In one recently published study, 10 female melasma patients, Fitzpatrick skin types II-IV, underwent five full-face low-energy, low-density (power 4-5 W, fluence 2-8 mJ, 2-8 passes) 1927-nm fractional thulium fiber laser treatment.2 Topical tranexamic acid was applied immediately after laser treatment and continued twice daily for 7 days. Seven patients completed the study. Based on the Global Aesthetics Improvement Scale (GAIS) ratings, all seven patients noted improvement at day 180, at which time six of the patients were considered to have improved from baseline, according to the investigator GAIS ratings. Using the Melasma Area Severity Index (MASI) score, the greatest degree of improvement was seen at day 90; there were three recurrences of melasma with worsening of the MASI score between day 90 and day 180.
In a split-face, double-blind, randomized controlled study, 46 patients with Fitzpatrick skin types III-V, with recalcitrant melasma received four weekly treatments of full-face fractional 1927-nm thulium laser; topical tranexamic acid was applied to one side of the face and normal saline applied to the other side under occlusion, immediately after treatment.3 At 3 months, significant improvements from baseline were seen with Melanin Index (MI) and modified MASI (mMASI) scores for the sides treated with tranexamic acid and the control side, with no statistically significant differences between the two. However, at month 6, among the 29 patients available for follow-up, significant differences in MI and mMASI scores from baseline were still evident, with the exception of MI scores on the control sides.
No adverse events from using topical tranexamic acid with laser were noted in either study. Split-face randomized control studies with use of topical tranexamic acid after fractional 1927-nm diode laser in comparison to fractional 1927-nm thulium laser would be notable in this vascular and heat-sensitive condition as well.
Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at [email protected]. They had no relevant disclosures.
References
1. Sheu SL. Cutis. 2018 Feb;101(2):E7-E8.
2. Wang, JV et al. J Cosmet Dermatol. 2021 Jan;20(1):105-9.
3. Wanitphakdeedecha R. et al. Lasers Med Sci. 2020 Dec;35(9):2015-21.
Should all skin cancer patients be taking nicotinamide?
In 2014, I began taking care of a patient (see photo) who had developed over 25 basal cell carcinomas on her lower legs, which were surgically removed. She has been clear of any skin cancers in the last 2 years since starting supplementation.
Nicotinamide, also known as niacinamide, is a water soluble form of vitamin B3 that has been shown to enhance the repair of UV-induced DNA damage. Nicotinamide is found naturally in meat, fish, nuts, grains, and legumes, and is a key component of the glycolysis pathway, by generating nicotinamide adenine dinucleotide for adenosine triphosphate production. Nicotinamide deficiency causes photosensitive dermatitis, diarrhea, and dementia. It has been studied for its anti-inflammatory benefits as an adjunct treatment for rosacea, bullous diseases, acne, and melasma.
Nonmelanoma skin cancers are known to be caused primarily by UV radiation. The supplementation of nicotinamide orally twice daily has been shown to reduce the rate of actinic keratoses and new nonmelanoma skin cancers compared with placebo after 1 year in patients who previously had skin cancer. In the phase 3 study published in 2015, a randomized, controlled trial of 386 patients who had at least two nonmelanoma skin cancers within the previous 5-year period, oral nicotinamide 500 mg given twice daily for a 12-month period significantly reduced the number of new nonmelanoma skin cancers by 23% versus those on placebo.
The recommended dose for nicotinamide, which is available over the counter as Vitamin B3, is 500 mg twice a day. Nicotinamide should not be confused with niacin (nicotinic acid), which has been used to treat high cholesterol and cardiovascular disease. There are no significant side effects from long-term use; however nicotinamide should not be used in patients with end-stage kidney disease or chronic kidney disease. (Niacin, however, can cause elevation of liver enzymes, headache, flushing, and increased blood pressure.) Nicotinamide crosses the placenta and should not be used in pregnancy as it has not been studied in pregnant populations.
We should counsel patients that this is not an oral sunscreen, and that sun avoidance, sunscreen, and yearly skin cancer checks are still the mainstay of skin cancer prevention. However, given the safety profile of nicotinamide and the protective effects, should all of our skin cancer patients be taking nicotinamide daily? In my practice they are, all of whom swear by it and have had significant reductions of both actinic keratoses and nonmelanoma skin cancers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
In 2014, I began taking care of a patient (see photo) who had developed over 25 basal cell carcinomas on her lower legs, which were surgically removed. She has been clear of any skin cancers in the last 2 years since starting supplementation.
Nicotinamide, also known as niacinamide, is a water soluble form of vitamin B3 that has been shown to enhance the repair of UV-induced DNA damage. Nicotinamide is found naturally in meat, fish, nuts, grains, and legumes, and is a key component of the glycolysis pathway, by generating nicotinamide adenine dinucleotide for adenosine triphosphate production. Nicotinamide deficiency causes photosensitive dermatitis, diarrhea, and dementia. It has been studied for its anti-inflammatory benefits as an adjunct treatment for rosacea, bullous diseases, acne, and melasma.
Nonmelanoma skin cancers are known to be caused primarily by UV radiation. The supplementation of nicotinamide orally twice daily has been shown to reduce the rate of actinic keratoses and new nonmelanoma skin cancers compared with placebo after 1 year in patients who previously had skin cancer. In the phase 3 study published in 2015, a randomized, controlled trial of 386 patients who had at least two nonmelanoma skin cancers within the previous 5-year period, oral nicotinamide 500 mg given twice daily for a 12-month period significantly reduced the number of new nonmelanoma skin cancers by 23% versus those on placebo.
The recommended dose for nicotinamide, which is available over the counter as Vitamin B3, is 500 mg twice a day. Nicotinamide should not be confused with niacin (nicotinic acid), which has been used to treat high cholesterol and cardiovascular disease. There are no significant side effects from long-term use; however nicotinamide should not be used in patients with end-stage kidney disease or chronic kidney disease. (Niacin, however, can cause elevation of liver enzymes, headache, flushing, and increased blood pressure.) Nicotinamide crosses the placenta and should not be used in pregnancy as it has not been studied in pregnant populations.
We should counsel patients that this is not an oral sunscreen, and that sun avoidance, sunscreen, and yearly skin cancer checks are still the mainstay of skin cancer prevention. However, given the safety profile of nicotinamide and the protective effects, should all of our skin cancer patients be taking nicotinamide daily? In my practice they are, all of whom swear by it and have had significant reductions of both actinic keratoses and nonmelanoma skin cancers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.
In 2014, I began taking care of a patient (see photo) who had developed over 25 basal cell carcinomas on her lower legs, which were surgically removed. She has been clear of any skin cancers in the last 2 years since starting supplementation.
Nicotinamide, also known as niacinamide, is a water soluble form of vitamin B3 that has been shown to enhance the repair of UV-induced DNA damage. Nicotinamide is found naturally in meat, fish, nuts, grains, and legumes, and is a key component of the glycolysis pathway, by generating nicotinamide adenine dinucleotide for adenosine triphosphate production. Nicotinamide deficiency causes photosensitive dermatitis, diarrhea, and dementia. It has been studied for its anti-inflammatory benefits as an adjunct treatment for rosacea, bullous diseases, acne, and melasma.
Nonmelanoma skin cancers are known to be caused primarily by UV radiation. The supplementation of nicotinamide orally twice daily has been shown to reduce the rate of actinic keratoses and new nonmelanoma skin cancers compared with placebo after 1 year in patients who previously had skin cancer. In the phase 3 study published in 2015, a randomized, controlled trial of 386 patients who had at least two nonmelanoma skin cancers within the previous 5-year period, oral nicotinamide 500 mg given twice daily for a 12-month period significantly reduced the number of new nonmelanoma skin cancers by 23% versus those on placebo.
The recommended dose for nicotinamide, which is available over the counter as Vitamin B3, is 500 mg twice a day. Nicotinamide should not be confused with niacin (nicotinic acid), which has been used to treat high cholesterol and cardiovascular disease. There are no significant side effects from long-term use; however nicotinamide should not be used in patients with end-stage kidney disease or chronic kidney disease. (Niacin, however, can cause elevation of liver enzymes, headache, flushing, and increased blood pressure.) Nicotinamide crosses the placenta and should not be used in pregnancy as it has not been studied in pregnant populations.
We should counsel patients that this is not an oral sunscreen, and that sun avoidance, sunscreen, and yearly skin cancer checks are still the mainstay of skin cancer prevention. However, given the safety profile of nicotinamide and the protective effects, should all of our skin cancer patients be taking nicotinamide daily? In my practice they are, all of whom swear by it and have had significant reductions of both actinic keratoses and nonmelanoma skin cancers.
Dr. Talakoub and Dr. Wesley are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected]. They had no relevant disclosures.