Aesthetic Dermatology

WAIKOLOA, HAWAII – Juvederm Voluma XC continues to show significant results in extended follow-up data from the pivotal phase III trial that earned the product marketing approval from the Food and Drug Administration late last year as the first filler indicated specifically for treating age-related midface volume deficit.

One of the notable new findings: At 6 months post treatment, 73% of Voluma-treated study participants rated themselves as looking younger than at baseline – and by an average of 5 years less than their mean baseline chronologic age of 56 years. Moreover, at 24 months, 55% of patients said they felt that they still looked younger by an average of 3 years, Dr. Sue Ellen Cox reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"The improvement was really profound. What was also profound was how long it lasted. I’m now 3 years out seeing these patients and they still have retention of their product. So I am a believer," said Dr. Cox, a dermatologist at the University of North Carolina at Chapel Hill, who was principal investigator in the pivotal phase III trial.

Dr. Cox shared highlights of the extended follow-up data, along with her personal observations regarding how to use Voluma most effectively.

Voluma XC is a highly cohesive volumizing hyaluronic acid filler formulated at a concentration of 20 mg/mL. It fills what has been widely regarded as a major unmet need in aesthetic dermatology, said Dr. Cox

"It’s a wonderful filler we’re all really going to enjoy using. I think it’s going to prove to be everything we want it to be," she said.

The pivotal data reviewed by the FDA came from a 15-center, randomized, single-blind clinical trial including 235 Voluma-treated patients and 47 no-treatment controls. All patients had moderate or severe baseline midface volume deficits as reflected by scores of 3-5 on a standardized 0-5 scoring system. The active treatment group received one treatment with the option of a touch-up session a month later.

The primary study endpoint prespecified by the FDA was an improvement of at least 1 point between baseline and 6 months on the Mid-Facial Volume Deficit Scale (MFVDS). This endpoint was achieved in 86% of the Voluma group and 39% of controls. Moreover, 51% of the active treatment group had an improvement of 2 points or greater compared with 11% of controls. And 26% of the Voluma group, but none of the controls, showed a 2.5-point improvement or better.

The durability of the treatment response was noteworthy, Dr. Cox added. At 2 years, 67% of patients in the Voluma group maintained a clinically significant improvement based upon MFVDS scores.

Every 3 months for the 2 years of follow-up, patients were asked how they felt about their appearance. As Dr. Cox noted, this is the true litmus test for any aesthetic dermatology procedure. At 6 months, 90% of patients pronounced themselves satisfied with the improvement in their facial appearance. At 12 months, 82% said they were satisfied; and at 2 years post treatment, 76% of patients remained satisfied with their facial appearance.

At baseline, 67% of patients rated their midface appearance as making them look "very much" older; at 6 months post treatment, only 12% of patients felt that way. Similarly, at baseline 55%-66% of patients characterized their midface appearance as variously "very much" unattractive, sad, and/or tired; at 6 months post treatment, only 9%-11% of subjects did so.

Treatment of the nasolabial folds and tear ducts was not permitted in the pivotal trial. Yet by investigator assessment at 6 months’ follow-up 32% of the active treatment group had a clinically meaningful improvement of at least 1 point on the 5-point Nasolabial Fold Photo Severity Scale, compared with 8% of controls, said Dr. Cox. Moreover, 54% of Voluma-treated patients rated themselves as moderately, very much, or completely satisfied with the appearance of their tear trough area, a marked improvement over the 17% rate at baseline. These findings underscore the point that effectively reinflating the midface and reestablishing optimal proportion provides ancillary benefits that may render treatment of the tear troughs and nasolabial folds unnecessary, she said.

Common treatment side effects consisted of mild to moderate injection site tenderness, swelling, bruising, lumps and bumps, and pain. All cases of side effects resolved within 30 days, and most resolved within 2 weeks.

Dr. Cox reported acting as a consultant to Allergan and Medicis and serving as principal investigator in trials funded by those companies, as well as in studies funded by Revance and Kythera.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Juvederm Voluma XC continues to show significant results in extended follow-up data from the pivotal phase III trial that earned the product marketing approval from the Food and Drug Administration late last year as the first filler indicated specifically for treating age-related midface volume deficit.

One of the notable new findings: At 6 months post treatment, 73% of Voluma-treated study participants rated themselves as looking younger than at baseline – and by an average of 5 years less than their mean baseline chronologic age of 56 years. Moreover, at 24 months, 55% of patients said they felt that they still looked younger by an average of 3 years, Dr. Sue Ellen Cox reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"The improvement was really profound. What was also profound was how long it lasted. I’m now 3 years out seeing these patients and they still have retention of their product. So I am a believer," said Dr. Cox, a dermatologist at the University of North Carolina at Chapel Hill, who was principal investigator in the pivotal phase III trial.

Dr. Cox shared highlights of the extended follow-up data, along with her personal observations regarding how to use Voluma most effectively.

Voluma XC is a highly cohesive volumizing hyaluronic acid filler formulated at a concentration of 20 mg/mL. It fills what has been widely regarded as a major unmet need in aesthetic dermatology, said Dr. Cox

"It’s a wonderful filler we’re all really going to enjoy using. I think it’s going to prove to be everything we want it to be," she said.

The pivotal data reviewed by the FDA came from a 15-center, randomized, single-blind clinical trial including 235 Voluma-treated patients and 47 no-treatment controls. All patients had moderate or severe baseline midface volume deficits as reflected by scores of 3-5 on a standardized 0-5 scoring system. The active treatment group received one treatment with the option of a touch-up session a month later.

The primary study endpoint prespecified by the FDA was an improvement of at least 1 point between baseline and 6 months on the Mid-Facial Volume Deficit Scale (MFVDS). This endpoint was achieved in 86% of the Voluma group and 39% of controls. Moreover, 51% of the active treatment group had an improvement of 2 points or greater compared with 11% of controls. And 26% of the Voluma group, but none of the controls, showed a 2.5-point improvement or better.

The durability of the treatment response was noteworthy, Dr. Cox added. At 2 years, 67% of patients in the Voluma group maintained a clinically significant improvement based upon MFVDS scores.

Every 3 months for the 2 years of follow-up, patients were asked how they felt about their appearance. As Dr. Cox noted, this is the true litmus test for any aesthetic dermatology procedure. At 6 months, 90% of patients pronounced themselves satisfied with the improvement in their facial appearance. At 12 months, 82% said they were satisfied; and at 2 years post treatment, 76% of patients remained satisfied with their facial appearance.

At baseline, 67% of patients rated their midface appearance as making them look "very much" older; at 6 months post treatment, only 12% of patients felt that way. Similarly, at baseline 55%-66% of patients characterized their midface appearance as variously "very much" unattractive, sad, and/or tired; at 6 months post treatment, only 9%-11% of subjects did so.

Treatment of the nasolabial folds and tear ducts was not permitted in the pivotal trial. Yet by investigator assessment at 6 months’ follow-up 32% of the active treatment group had a clinically meaningful improvement of at least 1 point on the 5-point Nasolabial Fold Photo Severity Scale, compared with 8% of controls, said Dr. Cox. Moreover, 54% of Voluma-treated patients rated themselves as moderately, very much, or completely satisfied with the appearance of their tear trough area, a marked improvement over the 17% rate at baseline. These findings underscore the point that effectively reinflating the midface and reestablishing optimal proportion provides ancillary benefits that may render treatment of the tear troughs and nasolabial folds unnecessary, she said.

Common treatment side effects consisted of mild to moderate injection site tenderness, swelling, bruising, lumps and bumps, and pain. All cases of side effects resolved within 30 days, and most resolved within 2 weeks.

Dr. Cox reported acting as a consultant to Allergan and Medicis and serving as principal investigator in trials funded by those companies, as well as in studies funded by Revance and Kythera.

SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Juvederm Voluma XC continues to show significant results in extended follow-up data from the pivotal phase III trial that earned the product marketing approval from the Food and Drug Administration late last year as the first filler indicated specifically for treating age-related midface volume deficit.

One of the notable new findings: At 6 months post treatment, 73% of Voluma-treated study participants rated themselves as looking younger than at baseline – and by an average of 5 years less than their mean baseline chronologic age of 56 years. Moreover, at 24 months, 55% of patients said they felt that they still looked younger by an average of 3 years, Dr. Sue Ellen Cox reported at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

"The improvement was really profound. What was also profound was how long it lasted. I’m now 3 years out seeing these patients and they still have retention of their product. So I am a believer," said Dr. Cox, a dermatologist at the University of North Carolina at Chapel Hill, who was principal investigator in the pivotal phase III trial.

Dr. Cox shared highlights of the extended follow-up data, along with her personal observations regarding how to use Voluma most effectively.

Voluma XC is a highly cohesive volumizing hyaluronic acid filler formulated at a concentration of 20 mg/mL. It fills what has been widely regarded as a major unmet need in aesthetic dermatology, said Dr. Cox

"It’s a wonderful filler we’re all really going to enjoy using. I think it’s going to prove to be everything we want it to be," she said.

The pivotal data reviewed by the FDA came from a 15-center, randomized, single-blind clinical trial including 235 Voluma-treated patients and 47 no-treatment controls. All patients had moderate or severe baseline midface volume deficits as reflected by scores of 3-5 on a standardized 0-5 scoring system. The active treatment group received one treatment with the option of a touch-up session a month later.

The primary study endpoint prespecified by the FDA was an improvement of at least 1 point between baseline and 6 months on the Mid-Facial Volume Deficit Scale (MFVDS). This endpoint was achieved in 86% of the Voluma group and 39% of controls. Moreover, 51% of the active treatment group had an improvement of 2 points or greater compared with 11% of controls. And 26% of the Voluma group, but none of the controls, showed a 2.5-point improvement or better.

The durability of the treatment response was noteworthy, Dr. Cox added. At 2 years, 67% of patients in the Voluma group maintained a clinically significant improvement based upon MFVDS scores.

Every 3 months for the 2 years of follow-up, patients were asked how they felt about their appearance. As Dr. Cox noted, this is the true litmus test for any aesthetic dermatology procedure. At 6 months, 90% of patients pronounced themselves satisfied with the improvement in their facial appearance. At 12 months, 82% said they were satisfied; and at 2 years post treatment, 76% of patients remained satisfied with their facial appearance.

At baseline, 67% of patients rated their midface appearance as making them look "very much" older; at 6 months post treatment, only 12% of patients felt that way. Similarly, at baseline 55%-66% of patients characterized their midface appearance as variously "very much" unattractive, sad, and/or tired; at 6 months post treatment, only 9%-11% of subjects did so.

Treatment of the nasolabial folds and tear ducts was not permitted in the pivotal trial. Yet by investigator assessment at 6 months’ follow-up 32% of the active treatment group had a clinically meaningful improvement of at least 1 point on the 5-point Nasolabial Fold Photo Severity Scale, compared with 8% of controls, said Dr. Cox. Moreover, 54% of Voluma-treated patients rated themselves as moderately, very much, or completely satisfied with the appearance of their tear trough area, a marked improvement over the 17% rate at baseline. These findings underscore the point that effectively reinflating the midface and reestablishing optimal proportion provides ancillary benefits that may render treatment of the tear troughs and nasolabial folds unnecessary, she said.

Common treatment side effects consisted of mild to moderate injection site tenderness, swelling, bruising, lumps and bumps, and pain. All cases of side effects resolved within 30 days, and most resolved within 2 weeks.

Dr. Cox reported acting as a consultant to Allergan and Medicis and serving as principal investigator in trials funded by those companies, as well as in studies funded by Revance and Kythera.

SDEF and this news organization are owned by the same parent company.

[email protected]

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

[email protected]

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

[email protected]

CHAMPIONSGATE, FLA. – "Aging doesn’t happen overnight," according to Dr. Wendy Roberts, medical director of Desert Dermatology in Rancho Mirage, Calif.

In a video interview at the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Roberts explained the concept of "generational dermatology" and how dermatologists are uniquely qualified to educate patients about taking a long-term, preventative approach to skin care.

[email protected]

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

[email protected]

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

[email protected]

CHAMPIONSGATE, FLA. – Patients seeking treatment for scars can benefit from a "restaurant menu" approach that involves using a series of techniques in a single visit, according to Dr. Jill Waibel, medical director of the Miami Dermatology and Laser Institute. At the Orlando Dermatology Aesthetic and Clinical Conference, Dr. Waibel spoke to us about one of her favorite strategies for scar treatment: a multiprocedure, multilaser protocol in a single visit that includes an "appetizer," such as a pulsed dye laser; followed by the "main course" of scar treatment, a fractional ablative device; and then "dessert" of adjunctive and topical therapies.

[email protected]

Many dermatologists continue to battle an overwashing epidemic. From bar soaps to antibacterial washes, dermatologists continue to educate patients that the extensive lather, the alkaline pH, and the antibacterial components of our washing rituals can strip the natural oils from the skin and leave it dry, cracked, and damaged.

This phenomenon is well reported in the literature, and industry has taken notice by developing more "no-soap" soaps than ever before.

But does the same philosophy apply to hair care practices? Hair washing is more complicated, particularly in skin of color patients.

Overwashing the hair often leads to dry hair, split ends, and the need for compensatory conditioners to replace lost moisture. In African American hair, especially that of patients who use chemical or heat treatments, the lost oil and sebum from overwashing can cause even more damage.

Many skin of color patients wash their hair infrequently to protect it from breakage, and they may use topical oils to smooth and protect the fragile hair shaft.

However, can underwashing the scalp and hair cause problems? Yes, in some cases.

You might see African American patients in your practice who are suffering from scalp folliculitis, itchy scalp, seborrheic dermatitis, or alopecia that can be traced to infrequent hair washing. The infrequency of washing and the application of oils to the hair does help the hair shaft, but the buildup of oils and sebum on the scalp itself can lead to scalp inflammation, follicular plugging, extensive seborrhea, acneiform eruptions, and folliculitis.

Depending on its level and degree, the inflammation can cause pruritus and burning of the scalp and can even lead to temporary or permanent hair loss. Although topical and oral antibiotics, topical steroids, and medicated shampoos do help, proper washing also plays an important preventative role.

For skin of color patients with some of the chronic scalp problems mentioned above, decreasing heat and chemical treatments, along with increasing hair washing to two or three times a week can help prevent scalp dermatitides without compromising the hair integrity. In addition, the use of sulfate-free shampoos, use of shampoo on the scalp only (without lathering the ends of the hair), or use of a dry shampoo between washes can help control the oil and product buildup on the scalp itself.

Ultimately, it may take some trial and error to find the right hair washing regimen for skin of color patients. Determining how often to wash the scalp depends on many patient-specific factors including ethnicity, hair type, frequency of chemical and heat treatments, cost, and level of scalp inflammation. Experimenting with new hair care products and possibly a new hairstyle also may be part of a successful treatment plan.

Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. A graduate of Boston University School of Medicine, Dr. Talakoub did her residency in dermatology at the University of California, San Francisco. She is the author of multiple scholarly articles and a textbook chapter.

Many dermatologists continue to battle an overwashing epidemic. From bar soaps to antibacterial washes, dermatologists continue to educate patients that the extensive lather, the alkaline pH, and the antibacterial components of our washing rituals can strip the natural oils from the skin and leave it dry, cracked, and damaged.

This phenomenon is well reported in the literature, and industry has taken notice by developing more "no-soap" soaps than ever before.

But does the same philosophy apply to hair care practices? Hair washing is more complicated, particularly in skin of color patients.

Overwashing the hair often leads to dry hair, split ends, and the need for compensatory conditioners to replace lost moisture. In African American hair, especially that of patients who use chemical or heat treatments, the lost oil and sebum from overwashing can cause even more damage.

Many skin of color patients wash their hair infrequently to protect it from breakage, and they may use topical oils to smooth and protect the fragile hair shaft.

However, can underwashing the scalp and hair cause problems? Yes, in some cases.

You might see African American patients in your practice who are suffering from scalp folliculitis, itchy scalp, seborrheic dermatitis, or alopecia that can be traced to infrequent hair washing. The infrequency of washing and the application of oils to the hair does help the hair shaft, but the buildup of oils and sebum on the scalp itself can lead to scalp inflammation, follicular plugging, extensive seborrhea, acneiform eruptions, and folliculitis.

Depending on its level and degree, the inflammation can cause pruritus and burning of the scalp and can even lead to temporary or permanent hair loss. Although topical and oral antibiotics, topical steroids, and medicated shampoos do help, proper washing also plays an important preventative role.

For skin of color patients with some of the chronic scalp problems mentioned above, decreasing heat and chemical treatments, along with increasing hair washing to two or three times a week can help prevent scalp dermatitides without compromising the hair integrity. In addition, the use of sulfate-free shampoos, use of shampoo on the scalp only (without lathering the ends of the hair), or use of a dry shampoo between washes can help control the oil and product buildup on the scalp itself.

Ultimately, it may take some trial and error to find the right hair washing regimen for skin of color patients. Determining how often to wash the scalp depends on many patient-specific factors including ethnicity, hair type, frequency of chemical and heat treatments, cost, and level of scalp inflammation. Experimenting with new hair care products and possibly a new hairstyle also may be part of a successful treatment plan.

Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. A graduate of Boston University School of Medicine, Dr. Talakoub did her residency in dermatology at the University of California, San Francisco. She is the author of multiple scholarly articles and a textbook chapter.

Many dermatologists continue to battle an overwashing epidemic. From bar soaps to antibacterial washes, dermatologists continue to educate patients that the extensive lather, the alkaline pH, and the antibacterial components of our washing rituals can strip the natural oils from the skin and leave it dry, cracked, and damaged.

This phenomenon is well reported in the literature, and industry has taken notice by developing more "no-soap" soaps than ever before.

But does the same philosophy apply to hair care practices? Hair washing is more complicated, particularly in skin of color patients.

Overwashing the hair often leads to dry hair, split ends, and the need for compensatory conditioners to replace lost moisture. In African American hair, especially that of patients who use chemical or heat treatments, the lost oil and sebum from overwashing can cause even more damage.

Many skin of color patients wash their hair infrequently to protect it from breakage, and they may use topical oils to smooth and protect the fragile hair shaft.

However, can underwashing the scalp and hair cause problems? Yes, in some cases.

You might see African American patients in your practice who are suffering from scalp folliculitis, itchy scalp, seborrheic dermatitis, or alopecia that can be traced to infrequent hair washing. The infrequency of washing and the application of oils to the hair does help the hair shaft, but the buildup of oils and sebum on the scalp itself can lead to scalp inflammation, follicular plugging, extensive seborrhea, acneiform eruptions, and folliculitis.

Depending on its level and degree, the inflammation can cause pruritus and burning of the scalp and can even lead to temporary or permanent hair loss. Although topical and oral antibiotics, topical steroids, and medicated shampoos do help, proper washing also plays an important preventative role.

For skin of color patients with some of the chronic scalp problems mentioned above, decreasing heat and chemical treatments, along with increasing hair washing to two or three times a week can help prevent scalp dermatitides without compromising the hair integrity. In addition, the use of sulfate-free shampoos, use of shampoo on the scalp only (without lathering the ends of the hair), or use of a dry shampoo between washes can help control the oil and product buildup on the scalp itself.

Ultimately, it may take some trial and error to find the right hair washing regimen for skin of color patients. Determining how often to wash the scalp depends on many patient-specific factors including ethnicity, hair type, frequency of chemical and heat treatments, cost, and level of scalp inflammation. Experimenting with new hair care products and possibly a new hairstyle also may be part of a successful treatment plan.

Dr. Talakoub is in private practice at McLean (Va.) Dermatology Center. A graduate of Boston University School of Medicine, Dr. Talakoub did her residency in dermatology at the University of California, San Francisco. She is the author of multiple scholarly articles and a textbook chapter.

WAIKOLOA, HAWAII – Just because a dermatologist has photodynamic therapy equipment in the office doesn’t mean it should be applied to every skin condition that comes through the door, Dr. Jerome M. Garden cautioned at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"Used selectively, I think PDT can be truly worthwhile in some of our patients. But we run into problems when we decide it’s a cure-all for everything. Just because it’s available does not always make it the best choice around," said Dr. Garden, who is director of the Physicians Laser and Dermatology Institute as well as a professor of clinical dermatology and biomedical engineering at Northwestern University in Chicago.

Looking through the literature, it’s quickly apparent that PDT has been used to treat a bewildering array of dermatologic disorders, in most cases with less than stellar results.

"In my practice, I’m using PDT to treat just two things: actinic keratoses and actinic cheilitis, which is a close cousin. Why am I not using it to treat more disease processes? Because it has to be worth it. PDT is not simple to do. It takes a lot of your time and it costs you money. Insurance doesn’t necessarily help you with this. Either the patient’s insurance will reimburse you at an incredibly low rate, where it’s basically costing you money to do it, or you go outside of the insurance – and PDT is an expensive procedure," he noted.

The substantial time expenditure involved in PDT stems from the need to use microdermabrasion or another method of skin preparation to help the topical photosensitizing agent penetrate better. This is followed by an incubation time of 1-3 hours as the photosensitizer finds its target, and then light therapy to create the reactive oxygen species, which kills the targeted cells. The duration of light therapy is source dependent; blue light, for example, must be applied for 15-20 minutes.

PDT has other shortcomings in addition to the cost and time involved. It can be painful and entails several days of down time because of scaling and crusting. Plus, multiple treatment sessions are usually required, the dermatologist continued.

The 2012 American Society for Dermatologic Surgery member survey found that dermatologic surgeons performed roughly 205,000 PDT procedures during the year. The bulk was for actinic keratoses, acne, and rosacea.

"I didn’t even know until I saw this list that anybody treats rosacea with PDT," noted Dr. Garden. "A lot of people out there who are doing PDT use it for many more things than I do. But I’m just telling you what I do."

"I’ve tried it for acne. It helps, but depending on the light source, it can be a painful procedure. There’s a lot of desquamation afterward, and you have to go through it a few times. So you have to have a highly motivated patient – and even then, it doesn’t work all the time," he said.

Dr. Garden cited a Danish split-face study of pulsed-dye laser-assisted PDT vs. pulsed-dye laser therapy alone. Twelve weeks after completing three treatment sessions, the PDT side showed an 80% reduction in inflammatory acne lesions, compared with a 67% drop with pulsed-dye laser, and a 53% decrease in noninflammatory lesions compared to a 42% reduction with laser alone (J. Am. Acad. Dermatol. 2008; 58:387-94).

"Even without the topical photosensitizer, patients did pretty well," he commented.

As for PDT in cutaneous malignancies, Dr. Garden highlighted a recent literature review by dermatologists at the University of South Florida, Tampa, which concluded that the therapy is equivalent or superior to cryosurgery for actinic keratoses. The investigators also deemed PDT suitable for Bowen’s disease lesions provided they are large, widespread, or on difficult to treat areas, as well as for squamous cell carcinomas, but only when surgery is contraindicated. PDT may also provide better cosmetic outcomes than surgery or cryosurgery for superficial basal cell carcinomas (Dermatol. Surg. 2013;39:1733-44).

Dr. Garden called PDT his current first-line treatment for actinic cheilitis.

"I used to use the CO₂ laser exclusively. It works very well, much better than PDT. But when I’d strip off the top layer of skin with the CO₂ laser, patients would end up with an open wound that took a long time to heal. That’s hard for the patient to tolerate. And occasionally we’d see fibrosis of the lip. You don’t see that with PDT, although with PDT you usually need to do two or three treatments, and the area is red and swollen for 2-4 days. I like PDT. It’s my go-to therapy. When it fails, I turn on the CO₂ laser," he said.

In treating actinic keratoses, he reserves PDT for patients with numerous lesions over a large field.

"It does work, but it’s a lot of effort. So if you’re just going after a handful of [actinic keratoses] do you need PDT? Probably not," Dr. Garden said.

Ending on an encouraging note, the dermatologist pointed to the ongoing substantial research commitment to PDT as very promising. Finding more specific photosensitizers is a priority. And ablative fractional laser-assisted delivery of the standard photosensitizer methyl aminolevulinic acid appears to be "an exciting development," in Dr. Garden’s view, although to date the work is limited to animal studies.

Dr. Garden reported having financial relationships with Alma, Candela & Syneron, and Palomar/Cynosure.

The SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Just because a dermatologist has photodynamic therapy equipment in the office doesn’t mean it should be applied to every skin condition that comes through the door, Dr. Jerome M. Garden cautioned at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"Used selectively, I think PDT can be truly worthwhile in some of our patients. But we run into problems when we decide it’s a cure-all for everything. Just because it’s available does not always make it the best choice around," said Dr. Garden, who is director of the Physicians Laser and Dermatology Institute as well as a professor of clinical dermatology and biomedical engineering at Northwestern University in Chicago.

Looking through the literature, it’s quickly apparent that PDT has been used to treat a bewildering array of dermatologic disorders, in most cases with less than stellar results.

"In my practice, I’m using PDT to treat just two things: actinic keratoses and actinic cheilitis, which is a close cousin. Why am I not using it to treat more disease processes? Because it has to be worth it. PDT is not simple to do. It takes a lot of your time and it costs you money. Insurance doesn’t necessarily help you with this. Either the patient’s insurance will reimburse you at an incredibly low rate, where it’s basically costing you money to do it, or you go outside of the insurance – and PDT is an expensive procedure," he noted.

The substantial time expenditure involved in PDT stems from the need to use microdermabrasion or another method of skin preparation to help the topical photosensitizing agent penetrate better. This is followed by an incubation time of 1-3 hours as the photosensitizer finds its target, and then light therapy to create the reactive oxygen species, which kills the targeted cells. The duration of light therapy is source dependent; blue light, for example, must be applied for 15-20 minutes.

PDT has other shortcomings in addition to the cost and time involved. It can be painful and entails several days of down time because of scaling and crusting. Plus, multiple treatment sessions are usually required, the dermatologist continued.

The 2012 American Society for Dermatologic Surgery member survey found that dermatologic surgeons performed roughly 205,000 PDT procedures during the year. The bulk was for actinic keratoses, acne, and rosacea.

"I didn’t even know until I saw this list that anybody treats rosacea with PDT," noted Dr. Garden. "A lot of people out there who are doing PDT use it for many more things than I do. But I’m just telling you what I do."

"I’ve tried it for acne. It helps, but depending on the light source, it can be a painful procedure. There’s a lot of desquamation afterward, and you have to go through it a few times. So you have to have a highly motivated patient – and even then, it doesn’t work all the time," he said.

Dr. Garden cited a Danish split-face study of pulsed-dye laser-assisted PDT vs. pulsed-dye laser therapy alone. Twelve weeks after completing three treatment sessions, the PDT side showed an 80% reduction in inflammatory acne lesions, compared with a 67% drop with pulsed-dye laser, and a 53% decrease in noninflammatory lesions compared to a 42% reduction with laser alone (J. Am. Acad. Dermatol. 2008; 58:387-94).

"Even without the topical photosensitizer, patients did pretty well," he commented.

As for PDT in cutaneous malignancies, Dr. Garden highlighted a recent literature review by dermatologists at the University of South Florida, Tampa, which concluded that the therapy is equivalent or superior to cryosurgery for actinic keratoses. The investigators also deemed PDT suitable for Bowen’s disease lesions provided they are large, widespread, or on difficult to treat areas, as well as for squamous cell carcinomas, but only when surgery is contraindicated. PDT may also provide better cosmetic outcomes than surgery or cryosurgery for superficial basal cell carcinomas (Dermatol. Surg. 2013;39:1733-44).

Dr. Garden called PDT his current first-line treatment for actinic cheilitis.

"I used to use the CO₂ laser exclusively. It works very well, much better than PDT. But when I’d strip off the top layer of skin with the CO₂ laser, patients would end up with an open wound that took a long time to heal. That’s hard for the patient to tolerate. And occasionally we’d see fibrosis of the lip. You don’t see that with PDT, although with PDT you usually need to do two or three treatments, and the area is red and swollen for 2-4 days. I like PDT. It’s my go-to therapy. When it fails, I turn on the CO₂ laser," he said.

In treating actinic keratoses, he reserves PDT for patients with numerous lesions over a large field.

"It does work, but it’s a lot of effort. So if you’re just going after a handful of [actinic keratoses] do you need PDT? Probably not," Dr. Garden said.

Ending on an encouraging note, the dermatologist pointed to the ongoing substantial research commitment to PDT as very promising. Finding more specific photosensitizers is a priority. And ablative fractional laser-assisted delivery of the standard photosensitizer methyl aminolevulinic acid appears to be "an exciting development," in Dr. Garden’s view, although to date the work is limited to animal studies.

Dr. Garden reported having financial relationships with Alma, Candela & Syneron, and Palomar/Cynosure.

The SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Just because a dermatologist has photodynamic therapy equipment in the office doesn’t mean it should be applied to every skin condition that comes through the door, Dr. Jerome M. Garden cautioned at the Hawaii Dermatology Seminar sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

"Used selectively, I think PDT can be truly worthwhile in some of our patients. But we run into problems when we decide it’s a cure-all for everything. Just because it’s available does not always make it the best choice around," said Dr. Garden, who is director of the Physicians Laser and Dermatology Institute as well as a professor of clinical dermatology and biomedical engineering at Northwestern University in Chicago.

Looking through the literature, it’s quickly apparent that PDT has been used to treat a bewildering array of dermatologic disorders, in most cases with less than stellar results.

"In my practice, I’m using PDT to treat just two things: actinic keratoses and actinic cheilitis, which is a close cousin. Why am I not using it to treat more disease processes? Because it has to be worth it. PDT is not simple to do. It takes a lot of your time and it costs you money. Insurance doesn’t necessarily help you with this. Either the patient’s insurance will reimburse you at an incredibly low rate, where it’s basically costing you money to do it, or you go outside of the insurance – and PDT is an expensive procedure," he noted.

The substantial time expenditure involved in PDT stems from the need to use microdermabrasion or another method of skin preparation to help the topical photosensitizing agent penetrate better. This is followed by an incubation time of 1-3 hours as the photosensitizer finds its target, and then light therapy to create the reactive oxygen species, which kills the targeted cells. The duration of light therapy is source dependent; blue light, for example, must be applied for 15-20 minutes.

PDT has other shortcomings in addition to the cost and time involved. It can be painful and entails several days of down time because of scaling and crusting. Plus, multiple treatment sessions are usually required, the dermatologist continued.

The 2012 American Society for Dermatologic Surgery member survey found that dermatologic surgeons performed roughly 205,000 PDT procedures during the year. The bulk was for actinic keratoses, acne, and rosacea.

"I didn’t even know until I saw this list that anybody treats rosacea with PDT," noted Dr. Garden. "A lot of people out there who are doing PDT use it for many more things than I do. But I’m just telling you what I do."

"I’ve tried it for acne. It helps, but depending on the light source, it can be a painful procedure. There’s a lot of desquamation afterward, and you have to go through it a few times. So you have to have a highly motivated patient – and even then, it doesn’t work all the time," he said.

Dr. Garden cited a Danish split-face study of pulsed-dye laser-assisted PDT vs. pulsed-dye laser therapy alone. Twelve weeks after completing three treatment sessions, the PDT side showed an 80% reduction in inflammatory acne lesions, compared with a 67% drop with pulsed-dye laser, and a 53% decrease in noninflammatory lesions compared to a 42% reduction with laser alone (J. Am. Acad. Dermatol. 2008; 58:387-94).

"Even without the topical photosensitizer, patients did pretty well," he commented.

As for PDT in cutaneous malignancies, Dr. Garden highlighted a recent literature review by dermatologists at the University of South Florida, Tampa, which concluded that the therapy is equivalent or superior to cryosurgery for actinic keratoses. The investigators also deemed PDT suitable for Bowen’s disease lesions provided they are large, widespread, or on difficult to treat areas, as well as for squamous cell carcinomas, but only when surgery is contraindicated. PDT may also provide better cosmetic outcomes than surgery or cryosurgery for superficial basal cell carcinomas (Dermatol. Surg. 2013;39:1733-44).

Dr. Garden called PDT his current first-line treatment for actinic cheilitis.

"I used to use the CO₂ laser exclusively. It works very well, much better than PDT. But when I’d strip off the top layer of skin with the CO₂ laser, patients would end up with an open wound that took a long time to heal. That’s hard for the patient to tolerate. And occasionally we’d see fibrosis of the lip. You don’t see that with PDT, although with PDT you usually need to do two or three treatments, and the area is red and swollen for 2-4 days. I like PDT. It’s my go-to therapy. When it fails, I turn on the CO₂ laser," he said.

In treating actinic keratoses, he reserves PDT for patients with numerous lesions over a large field.

"It does work, but it’s a lot of effort. So if you’re just going after a handful of [actinic keratoses] do you need PDT? Probably not," Dr. Garden said.

Ending on an encouraging note, the dermatologist pointed to the ongoing substantial research commitment to PDT as very promising. Finding more specific photosensitizers is a priority. And ablative fractional laser-assisted delivery of the standard photosensitizer methyl aminolevulinic acid appears to be "an exciting development," in Dr. Garden’s view, although to date the work is limited to animal studies.

Dr. Garden reported having financial relationships with Alma, Candela & Syneron, and Palomar/Cynosure.

The SDEF and this news organization are owned by the same parent company.

[email protected]

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

WAIKOLOA, HAWAII – Our editor, Heidi Splete, catches up with attendees at the Hawaii Dermatology Seminar to find out what they learned at the meeting that they will take back to their practices.

During a coffee break video interview, doctors said they enjoyed presentations on tips to treat fine lines around the eyes and mouth, the link between psoriasis and increased cardiovascular risks, and the "two Cs" of potential leather allergies.

[email protected]

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

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

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

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

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

Sources:

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

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

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

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

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

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

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

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

Sources:

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

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

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

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

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

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

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

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

Sources:

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

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

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

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

[email protected]

On Twitter @hsplete

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

[email protected]

On Twitter @hsplete

CHAMPIONSGATE, FLA. – Injections of botulinum neurotoxin type A on the nose, cheeks, and chin can significantly improve the appearance of some rosacea patients, in part by reducing overactivity of the sebaceous gland, according to Dr. Erin Gilbert of SUNY Downstate Medical Center, New York.

"I have had remarkably consistent results" using neuromodulators to treat patients with papulopustular and erythematotelangiectatic rosacea, Dr. Gilbert said in a presentation at the Orlando Dermatology Aesthetic and Clinical Conference.

Current therapies for rosacea include topical antibiotics, azelaic acid, metronidazole, sodium sulfacetamide, and the recently approved brimonidine, Dr. Gilbert said. Subantimicrobially dosed doxycycline remains the first and only oral therapy currently approved by the Food and Drug Administration, she noted.

Botulinum toxin represents a cutting-edge treatment option for rosacea that capitalizes on the skin’s biochemistry: Specific neuropeptide genes are up- or downregulated in rosacea patients, explained Dr. Gilbert, who also holds a Ph.D. in neural and behavioral sciences.

In addition, the expression of non-neuronal transient receptor potential (TRPV2, 3, and 4) ion channels is differentially upregulated in phymatous, erythematotelangiectatic, and papulopustular rosacea subtypes, she said.

When botulinum toxin type A is injected in the nose, cheeks, and chin of rosacea patients, the sebaceous gland activity and vasodilatory responses decrease. This translates to clinical findings, including reduced flushing and oil production, decreased inflammatory lesion counts, and reduced pore size, said Dr. Gilbert.

"The question is, what’s the mechanism?" she said. The answer: "Rosacea is likely improving when nerves stop talking to blood vessels and to the immune system."

For what it is worth, histology on patients with papulopustular and erythematotelangiectatic rosacea shows significant fibrosis, she noted.

Additional research is needed, but Dr. Steven H. Dayan of the University of Illinois, Chicago, and his colleagues published data on a short series of 13 patients in the Journal of Drugs in Dermatology. Their data showed substantial reduction of flushing, redness, and inflammation within a week of treatment, with effects lasting up to 3 months. No adverse events were reported (J. Drugs Dermatol. 2012;11:e76-e79).

To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Dr. Gilbert has served as a consultant for Merz Aesthetics, Allergan, and Medicis Aesthetics, and as a consultant and speaker for Johnson & Johnston and Glytone.

[email protected]

On Twitter @hsplete

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Could it be the carbs?

In my practice, I have observed consistent improvements in recalcitrant perioral dermatitis when patients switch to low-carbohydrate diets. Several of my patients with perioral dermatitis that responded poorly to oral doxycycline, topical metronidazole, and topical tacrolimus – or recurred upon cessation of therapy – have proven to have gluten sensitivity or intolerance. Their skin condition improves when they go on a gluten-free diet. But I have also seen considerable improvements after patients undertake low-carbohydrate, high-protein diets, even if those patients have no diagnosed gluten sensitivity. These improvements have occurred with minimal oral and topical treatments, and these patients have not experienced recurrences.

There have been no well-controlled studies, or even case reports to my knowledge, linking carbohydrate or gluten intake to perioral dermatitis. Could the improvement be serendipitous, or is there some basis for carbohydrates contributing to inflammatory status in the oral and gastrointestinal mucosa?

Alcohol, spicy foods, and chocolate have been linked to exacerbation of erythemogenic and papulopustular rosacea. However, the precipitating ingredients in these foods have not been identified. Could the common link simply be an abundance of carbohydrates?

More studies are needed to better define the role of diet in perioral dermatitis. In the meantime, I am seeing good results with low-carb/carb-free diets and will continue to suggest them to prevent recurrences in my patients with perioral dermatitis.

Dr. Talakoub is in private practice in McLean, Va.

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].

Many clinicians are unaware that ethnic populations in North America do not achieve optimal serum 25-hydroxyvitamin D (abbreviated 25[OH]D) because of the increased pigmentation in their skin, which reduces vitamin D production. Vitamin D insufficiency is more prevalent among individuals with darker skin, compared with those with lighter skin at any time of year, even during the winter months. Contributing to the deficiency, the dietary intake of vitamin D intake among African Americans in particular is often below the recommended intakes in every age group after puberty. However, data have shown vitamin D protects against Sjögren’s syndrome, psoriasis, type 1 and type 2 diabetes, multiple sclerosis, and rheumatoid arthritis.

Vitamin D also may protect against cardiovascular disease through its anti-inflammatory effects and may reduce the risk for colorectal cancer, breast cancer, and prostate cancer by promoting cell differentiation and down-regulating hyperproliferative cell growth. Most of these conditions have been shown to be as prevalent, if not more prevalent, among blacks than whites.

While vitamin D can be obtained from sun exposure, this is not always a viable option. UV exposure is linked to skin cancer, which leads clinicians to encourage sun avoidance, but they may disregard the need for vitamin D. In addition, darker pigmentation of the skin reduces vitamin D synthesis in the skin.

How can you help your skin of color patients get enough vitamin D, especially in the winter? Nutritional sources of vitamin D include salmon, sardines, and cows’ milk; however, many individuals do not achieve optimal vitamin D status from food intake alone.

Since UV exposure and diet are not sufficient sources of vitamin D, supplementation has become crucial to our patients, particularly those with darker skin. Dietary reference intakes for vitamin D have been under considerable scrutiny, and many experts now believe that intakes of 25 mcg/d (1,000 IU) or more may be needed for most people to achieve optimal blood levels of 25(OH)D. The two forms of vitamin D used in dietary supplements are ergocalciferol (vitamin D₂) and cholecalciferol (vitamin D₃). Cholecalciferol, the D₃ form of the vitamin, is the form of choice when supplementing with vitamin D. Types of D₃ supplements include gel caps, liquid, powders, and tablets. Vitamin D is often measured in International Units (IU) or mcg. One mcg of cholecalciferol is equal to 40 IU of vitamin D.

The debate continues over the most effective forms of vitamin D acquisition; however, many health professionals agree that vitamin D supplementation, particularly in winter months, should be an integral part of our armamentarium of therapeutics for ethnic patients, and especially those who suffer from psoriasis and other autoimmune and inflammatory skin conditions.

Dr. Talakoub is in private practice in McLean, Va.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].