Aesthetic Dermatology Update

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

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

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

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

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

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

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

Resource:

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

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

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

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

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

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

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

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

Resource:

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

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

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

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

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

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

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

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

Resource:

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

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

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.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

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.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

 

The therapeutic benefits of plant oils have been documented for hundreds of years. The properties of medicinal and aromatic plants have been explored for their essential oils. Essential oils are synthesized and used in a multibillion dollar global market for their curative properties, which include antimicrobial, antioxidant, anti-inflammatory, chemoprotective, antiproliferative, antiatherogenic, and antidiabetic properties. More than 80% of the global population depends on traditional plant-based medicine for treating health problems. There are currently over 3,000 known essential oils, among which 300 are commercially available for food, pharmaceutical, cosmetic, sanitary, and perfume industries. The extraction of these oils and their use in cosmeceuticals has increased in the last decade, as minor ingredients in creams and skin cleansing preparations.

However, these oils are now being marketed for direct application on the skin. What’s the hype about facial oils and why are there hundreds currently on the market?

Contrary to popular belief, oils are not solely for dry skin. Plant-based oils are filled with essential fatty acids, vitamins, and antioxidants that act to strengthen the skin’s protective barrier, prevent free radical damage, and increase skin elasticity. The chemical constituents of plant essential oils differ among species. Factors influencing these constituents include geographical location, environment, and stage of maturity of the plant. Furthermore, the stereochemical properties of essential oils can vary and depend on the method of extraction. There are over fifty different types of fatty acids in oils, and each oil has its own unique composition.

Choosing the right oil, however, is not easy. Most consumers shy away from pure oils because they fear breakouts or increased “oiliness” of their skin. Understanding the properties of the oils can help determine which oils will benefit specific skin types. Argan oil and sunflower oil, for example, are rich in essential fatty acids and vitamin E, which hydrate the skin and have antiaging properties. Tea tree oil has antibacterial and anti-inflammatory qualities which are great for acne-prone skin. Oils such as these are particularly effective if acne medications are used. Acne medications can strip the natural barrier of the skin and without proper hydration excess sebum is produced and can cause clogging of pores.

Skin oils help to repair the skin barrier and train the skin to rebalance itself if overstripped from harsh cleansers or medications. Rosehip seed oil, previously used by Native Americans for its healing properties, has regained popularity because it is a rich source of Vitamin E, C, D, A, and essential fatty acids. Cosmetic preparations of rosehip oil have been used for hydration, scar reduction, stretch marks, and decreasing facial erythema with rosacea.

Essential oils have antiaging properties as well. A study of sixty postmenopausal women who received oral or topical argan oil had significantly improved elasticity of the skin after 60 days, compared with the consumption of olive oil, which produced no improvement of skin elasticity. Sunflower oil has been used in skin preparations for its rich antioxidant properties, which decrease free radical damage from UV radiation.

The use of oils is multidimensional. Oils are highly effective for removing makeup and are the best source for cleansing of dry, dehydrated, or sensitive skin. Similarly, oils applied to the hair can help restore the natural oils of the hair, which are often stripped from overwashing and from chemical hair treatments. Facial oils also help improve skin hydration and restore the natural barrier of the skin. In addition, facial oils can be used in place of moisturizers or under a moisturizer to help prevent transepidermal water loss in dehydrated or atopic skin.

But these oils have a downside. Fragrant plant-based oils can cause skin irritation, photosensitivity, and potentially, allergic reactions. Consumers with plant-based allergies or sensitive skin should therefore steer clear of fragrant oils and test every oil on their inner forearm prior to applying them on the face.

I am a believer in these products. Oils have come a long way in cosmetic products and their manufacturing process has been improved over the last decade, making them easy to use, noncomedogenic, and nongreasy. They are an essential part of skin care for anyone with inflamed, dry, or irritated skin. More cosmetically elegant than their predecessors, when used correctly, oils are among the best products in the cosmeceutical market today.

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.

 

References

J Pharm Pharmacol. 2010 Dec;62(12):1669-75.

Inflamm Allergy Drug Targets. 2014;13(3):168-76.

Issue Biol. Sci. Pharm. Res. 2(1):001-007.

Evid Based Complement Alternat Med. 2017;2017:4517971.

Clin Interv Aging. 2015; 10: 339-49.

Evid Based Complement Alternat Med. 2013;2013:827248.

Dermatoendocrinol. 2012 Jul 1;4(3):298-307.

http://www.circulating-oils-library.com/en/start.

 

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

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

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

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

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

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

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

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

References:

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

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

 

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

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

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

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

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

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

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

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

References:

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

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

 

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

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

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

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

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

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

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

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

References:

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

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

 

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

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

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

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

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

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

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


 

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

References

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

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

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

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

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

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

 

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

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

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

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

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

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

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


 

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

References

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

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

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

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

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

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

 

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

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

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

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

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

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

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


 

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

2. Burns. 2010 Aug;36(5):639-46.
 

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

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

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

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

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

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

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

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

References

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

2. Burns. 2010 Aug;36(5):639-46.
 

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

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

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

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

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

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

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

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

References

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

2. Burns. 2010 Aug;36(5):639-46.
 

 

There are many, many, short-term and long-term consequences of sleep deprivation. The most clinically apparent ones – swollen, sunken eyes; dark circles; and pale, dehydrated skin – are obvious. However the subclinical consequences are not so obvious. Sleep deprivation affects wound healing, collagen growth, skin hydration, and skin texture. Inflammation is also higher in sleep-deprived patients, causing outbreaks of acne, eczema, psoriasis, and skin allergies.

Sleep deprivation can be caused by artificial light, shift work, sleep disturbances, and social life. Studies have shown that sleep plays a role in restoring the immune system function and that changes in the immune response triggered by high-stress states such as sleep deprivation affect collagen production. Several studies of prolonged sleep deprivation also suggest breaks in skin barrier function. Rats subjected to prolonged periods of sleep loss in a study developed ulcerative lesions on their paws and tails, and susceptibility to bacterial infection.

The reduction of sleep time affects the composition and integrity of the skin. Sleep deprivation increases glucocorticoid production. The elevation of cortisol inhibits fibroblast function and increases matrix metalloproteinases (collagenase, gelatinase). Matrix metalloproteinases accelerate collagen and elastin breakdown, which is essential to skin integrity, and hastens the aging process by increasing wrinkles, decreasing skin thickness, inhibiting growth factors, and decreasing skin elasticity.

Are there treatments to reverse these signs? Yes. Treatments to help increase skin collagen production include microneedling, radiofrequency devices, fractionated lasers, and topical agents such as retinoids. However, we cannot readily reverse the impact inflammatory processes, skin barrier dysfunction, or the disruption of the skin biome has on our skin. Beauty sleep is both necessary and irreplaceable.
 

References

1. Am J Physiol. 1993 Nov;265(5 Pt 2):R1148-54.

2. Am J Physiol Regul Integr Comp Physiol. 2000 Apr;278(4):R905-16.

3. Am J Physiol Regul Integr Comp Physiol. 2005 Feb;288(2):R374-83.

4. Am J Physiol Regul Integr Comp Physiol. 2007 Jul;293(1):R504-9.

5. Med Hypotheses. 2010 Dec;75(6):535-7.

6. Sleep. 2013 Sep 1;36(9):1355-60.

7. BMJ. 2010 Dec 14;341:c6614.

8. Brain Behav Immun. 2009 Nov;23(8):1089-95.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

 

There are many, many, short-term and long-term consequences of sleep deprivation. The most clinically apparent ones – swollen, sunken eyes; dark circles; and pale, dehydrated skin – are obvious. However the subclinical consequences are not so obvious. Sleep deprivation affects wound healing, collagen growth, skin hydration, and skin texture. Inflammation is also higher in sleep-deprived patients, causing outbreaks of acne, eczema, psoriasis, and skin allergies.

Sleep deprivation can be caused by artificial light, shift work, sleep disturbances, and social life. Studies have shown that sleep plays a role in restoring the immune system function and that changes in the immune response triggered by high-stress states such as sleep deprivation affect collagen production. Several studies of prolonged sleep deprivation also suggest breaks in skin barrier function. Rats subjected to prolonged periods of sleep loss in a study developed ulcerative lesions on their paws and tails, and susceptibility to bacterial infection.

The reduction of sleep time affects the composition and integrity of the skin. Sleep deprivation increases glucocorticoid production. The elevation of cortisol inhibits fibroblast function and increases matrix metalloproteinases (collagenase, gelatinase). Matrix metalloproteinases accelerate collagen and elastin breakdown, which is essential to skin integrity, and hastens the aging process by increasing wrinkles, decreasing skin thickness, inhibiting growth factors, and decreasing skin elasticity.

Are there treatments to reverse these signs? Yes. Treatments to help increase skin collagen production include microneedling, radiofrequency devices, fractionated lasers, and topical agents such as retinoids. However, we cannot readily reverse the impact inflammatory processes, skin barrier dysfunction, or the disruption of the skin biome has on our skin. Beauty sleep is both necessary and irreplaceable.
 

References

1. Am J Physiol. 1993 Nov;265(5 Pt 2):R1148-54.

2. Am J Physiol Regul Integr Comp Physiol. 2000 Apr;278(4):R905-16.

3. Am J Physiol Regul Integr Comp Physiol. 2005 Feb;288(2):R374-83.

4. Am J Physiol Regul Integr Comp Physiol. 2007 Jul;293(1):R504-9.

5. Med Hypotheses. 2010 Dec;75(6):535-7.

6. Sleep. 2013 Sep 1;36(9):1355-60.

7. BMJ. 2010 Dec 14;341:c6614.

8. Brain Behav Immun. 2009 Nov;23(8):1089-95.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

 

There are many, many, short-term and long-term consequences of sleep deprivation. The most clinically apparent ones – swollen, sunken eyes; dark circles; and pale, dehydrated skin – are obvious. However the subclinical consequences are not so obvious. Sleep deprivation affects wound healing, collagen growth, skin hydration, and skin texture. Inflammation is also higher in sleep-deprived patients, causing outbreaks of acne, eczema, psoriasis, and skin allergies.

Sleep deprivation can be caused by artificial light, shift work, sleep disturbances, and social life. Studies have shown that sleep plays a role in restoring the immune system function and that changes in the immune response triggered by high-stress states such as sleep deprivation affect collagen production. Several studies of prolonged sleep deprivation also suggest breaks in skin barrier function. Rats subjected to prolonged periods of sleep loss in a study developed ulcerative lesions on their paws and tails, and susceptibility to bacterial infection.

The reduction of sleep time affects the composition and integrity of the skin. Sleep deprivation increases glucocorticoid production. The elevation of cortisol inhibits fibroblast function and increases matrix metalloproteinases (collagenase, gelatinase). Matrix metalloproteinases accelerate collagen and elastin breakdown, which is essential to skin integrity, and hastens the aging process by increasing wrinkles, decreasing skin thickness, inhibiting growth factors, and decreasing skin elasticity.

Are there treatments to reverse these signs? Yes. Treatments to help increase skin collagen production include microneedling, radiofrequency devices, fractionated lasers, and topical agents such as retinoids. However, we cannot readily reverse the impact inflammatory processes, skin barrier dysfunction, or the disruption of the skin biome has on our skin. Beauty sleep is both necessary and irreplaceable.
 

References

1. Am J Physiol. 1993 Nov;265(5 Pt 2):R1148-54.

2. Am J Physiol Regul Integr Comp Physiol. 2000 Apr;278(4):R905-16.

3. Am J Physiol Regul Integr Comp Physiol. 2005 Feb;288(2):R374-83.

4. Am J Physiol Regul Integr Comp Physiol. 2007 Jul;293(1):R504-9.

5. Med Hypotheses. 2010 Dec;75(6):535-7.

6. Sleep. 2013 Sep 1;36(9):1355-60.

7. BMJ. 2010 Dec 14;341:c6614.

8. Brain Behav Immun. 2009 Nov;23(8):1089-95.
 

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

 

With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.

A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.¹ The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.

Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.² It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.

Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.

The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.³ While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.

References

1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.

2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.

3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.

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

 

With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.

A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.¹ The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.

Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.² It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.

Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.

The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.³ While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.

References

1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.

2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.

3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.

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

 

With loss of deep fat pad compartments and bony resorption with normal aging, soft tissue fillers have become a mainstay in minimally invasive aesthetic treatments. Preference of injecting with a needle versus a cannula is often user and training dependent. Blunt-tipped cannulas may provide a lower risk of bruising, as well as potentially devastating complications such as intravascular occlusion that can lead to skin necrosis and blindness. Even for advanced injectors, however, cannula use may portend a learning curve if the clinicians are used to injecting with needles.

A recently published observational study using cadaver heads looked at precision in supraperiosteal placement with a sharp needle compared with a blunt tipped cannula.¹ The investigators injected dye material with soft-tissue fillers at different aesthetic facial sites on the supraperiosteum, then observed the placement of dye and filler after dissection. In this study, the placement of product was more precise with the cannulas. The filler was injected on the periosteum with a needle. Some of the filler then migrated along the trajectory of the needle path back toward the epidermis, ending up in multiple tissue layers. So there was more extrusion of the filler in the superficial layers with a needle without a retrograde injection technique. Even with the needle tip on the periosteum and no movement of the needle, the needle technique showed a higher risk of intra-arterial injections. This study is limited by the fact that in vivo circumstances could potentially alter the outcome, as could user injection technique.

Cannulas should be highly considered in any deep tissue compartment, but especially in more advanced injection technique areas, such as the nasal dorsum. Another cadaver study from Thailand showed that the anatomy of the dorsal nasal artery is not consistent.² It is injection into this artery that can lead to blindness via flow to the ophthalmic artery. The study showed that both the diameter of the artery and the presence of a single or bilateral dorsal nasal artery varied. The dorsal nasal artery travels in the subcutaneous tissue layer of the nasal dorsum on the transverse nasalis muscle and its midline nasal aponeurosis, which connects the muscles on both sides. Bilateral dorsal nasal arteries were present in 34% of the specimens. A single and large dorsal nasal artery was present in 28%.

Needles are still useful in some places where precise small aliquot touch-up of filler placement is needed or where it may be difficult to reach with the cannula without making an additional portal of entry. More viscous fillers such as calcium hydroxylapatite and poly-L-lactic acid can be difficult to inject through a cannula and require a needle for injection. More superficially, small 30- or 32-gauge needles are also required for the injection of certain hyaluronic acid fillers in the superficial dermis for more etched lines.

The risk of arterial wall perforation and emboli with cannulas is lower, but these complications can still occur. The risk increases with a perpendicular angle between the artery and the cannula, thus slow small aliquot injection technique along with knowledge of anatomy is essential.³ While both needles and cannulas are useful in practice and achieve excellent cosmetic results, cannula use in the deeper compartments among practitioners is encouraged to minimize complications.

References

1. Aesthet Surg J. 2016 Dec 16. pii: sjw220.

2. Aesthetic Plast Surg. 2016 Dec 28. doi: 10.1007/s00266-016-0756-0.

3. Aesthetic Plast Surg. 2016 Dec 23. doi: 10.1007/s00266-016-0725-7.

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

 

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

It’s clear that UV exposure and visible light are the predominant triggers in the development of melasma. Recent studies looking at biopsies of lesional skin in melasma patients show similarity to solar-damaged skin. Solar elastosis has been shown to be secondary to the synthesis of alpha-melanocyte stimulating hormone (alpha-MSH) and adrenocorticotropic hormone (ACTH) derived from pro-opiomelanocortin (POMC) in keratinocytes. These peptides lead to proliferation of melanocytes, as well as increase in melanin synthesis via stimulation of tyrosinase activity and tyrosinase-related protein 1 (TRP-1).

Similarly, elevated estrogen and progesterone in pregnancy or with oral contraceptive use is known to stimulate melasma. Melanocytes express estrogen receptors and estradiol increases the level of TRP-2, which stimulates melanocytes to produce melanin. Recent literature has shown that the number of blood vessels, vessel size, and vessel density also are greater in lesional melasma skin than in perilesional skin. In addition, immunohistochemical staining has shown an increased level of factor VIIIa-related antigen in blood vessels in melasma skin, compared with perilesional normal skin.

Courtesy Lily Talakoub, MD

Elevated vascular endothelial growth factor (VEGF) in keratinocytes also has been hypothesized to play a role in the elevated vascularization of melasma. Biopsies from affected skin also reveal increases in mast cells that release mediators – including histamine, VEGF, tumor necrosis factor-alpha, and interleukin-8 – which promote vascular proliferation. The evidence now points to these stimuli triggering angiogenesis, leading to release of mediators that cause melanocyte activation and melanin production.

Unfortunately, the treatment of vascular melasma is very difficult. Lasers such as the pulsed dye laser that help skin vascularity can trigger worsening melanogenesis through dermal inflammation. The melanin cap overlying the melanocyte nucleus also can mask the underlying vascularity and make laser treatments more difficult. The isolated treatment of epidermal pigment also may be ineffective and transient.

By targeting the vessels in addition to the pigment, we will get improved clinical results and fewer relapses. We suggest that melasma be treated conservatively, not aggressively. It should be treated as an inflammatory process. Patients with melasma also have a slightly abnormal skin barrier, so we should be hesitant in using deep lasers, radio frequency, and aggressive chemical peels. Topical preparations – particularly triple-combination bleaching agents, retinoids, and nonhydroquinone skin lighteners – should be used sparingly and always in combination with treatments targeting skin vascularity.
 

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

 

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

It’s clear that UV exposure and visible light are the predominant triggers in the development of melasma. Recent studies looking at biopsies of lesional skin in melasma patients show similarity to solar-damaged skin. Solar elastosis has been shown to be secondary to the synthesis of alpha-melanocyte stimulating hormone (alpha-MSH) and adrenocorticotropic hormone (ACTH) derived from pro-opiomelanocortin (POMC) in keratinocytes. These peptides lead to proliferation of melanocytes, as well as increase in melanin synthesis via stimulation of tyrosinase activity and tyrosinase-related protein 1 (TRP-1).

Similarly, elevated estrogen and progesterone in pregnancy or with oral contraceptive use is known to stimulate melasma. Melanocytes express estrogen receptors and estradiol increases the level of TRP-2, which stimulates melanocytes to produce melanin. Recent literature has shown that the number of blood vessels, vessel size, and vessel density also are greater in lesional melasma skin than in perilesional skin. In addition, immunohistochemical staining has shown an increased level of factor VIIIa-related antigen in blood vessels in melasma skin, compared with perilesional normal skin.

Courtesy Lily Talakoub, MD

Elevated vascular endothelial growth factor (VEGF) in keratinocytes also has been hypothesized to play a role in the elevated vascularization of melasma. Biopsies from affected skin also reveal increases in mast cells that release mediators – including histamine, VEGF, tumor necrosis factor-alpha, and interleukin-8 – which promote vascular proliferation. The evidence now points to these stimuli triggering angiogenesis, leading to release of mediators that cause melanocyte activation and melanin production.

Unfortunately, the treatment of vascular melasma is very difficult. Lasers such as the pulsed dye laser that help skin vascularity can trigger worsening melanogenesis through dermal inflammation. The melanin cap overlying the melanocyte nucleus also can mask the underlying vascularity and make laser treatments more difficult. The isolated treatment of epidermal pigment also may be ineffective and transient.

By targeting the vessels in addition to the pigment, we will get improved clinical results and fewer relapses. We suggest that melasma be treated conservatively, not aggressively. It should be treated as an inflammatory process. Patients with melasma also have a slightly abnormal skin barrier, so we should be hesitant in using deep lasers, radio frequency, and aggressive chemical peels. Topical preparations – particularly triple-combination bleaching agents, retinoids, and nonhydroquinone skin lighteners – should be used sparingly and always in combination with treatments targeting skin vascularity.
 

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].

 

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

It’s clear that UV exposure and visible light are the predominant triggers in the development of melasma. Recent studies looking at biopsies of lesional skin in melasma patients show similarity to solar-damaged skin. Solar elastosis has been shown to be secondary to the synthesis of alpha-melanocyte stimulating hormone (alpha-MSH) and adrenocorticotropic hormone (ACTH) derived from pro-opiomelanocortin (POMC) in keratinocytes. These peptides lead to proliferation of melanocytes, as well as increase in melanin synthesis via stimulation of tyrosinase activity and tyrosinase-related protein 1 (TRP-1).

Similarly, elevated estrogen and progesterone in pregnancy or with oral contraceptive use is known to stimulate melasma. Melanocytes express estrogen receptors and estradiol increases the level of TRP-2, which stimulates melanocytes to produce melanin. Recent literature has shown that the number of blood vessels, vessel size, and vessel density also are greater in lesional melasma skin than in perilesional skin. In addition, immunohistochemical staining has shown an increased level of factor VIIIa-related antigen in blood vessels in melasma skin, compared with perilesional normal skin.

Courtesy Lily Talakoub, MD

Elevated vascular endothelial growth factor (VEGF) in keratinocytes also has been hypothesized to play a role in the elevated vascularization of melasma. Biopsies from affected skin also reveal increases in mast cells that release mediators – including histamine, VEGF, tumor necrosis factor-alpha, and interleukin-8 – which promote vascular proliferation. The evidence now points to these stimuli triggering angiogenesis, leading to release of mediators that cause melanocyte activation and melanin production.

Unfortunately, the treatment of vascular melasma is very difficult. Lasers such as the pulsed dye laser that help skin vascularity can trigger worsening melanogenesis through dermal inflammation. The melanin cap overlying the melanocyte nucleus also can mask the underlying vascularity and make laser treatments more difficult. The isolated treatment of epidermal pigment also may be ineffective and transient.

By targeting the vessels in addition to the pigment, we will get improved clinical results and fewer relapses. We suggest that melasma be treated conservatively, not aggressively. It should be treated as an inflammatory process. Patients with melasma also have a slightly abnormal skin barrier, so we should be hesitant in using deep lasers, radio frequency, and aggressive chemical peels. Topical preparations – particularly triple-combination bleaching agents, retinoids, and nonhydroquinone skin lighteners – should be used sparingly and always in combination with treatments targeting skin vascularity.
 

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub. Write to them at [email protected].