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Less vacuum may reduce post–cryolipolysis adipose hyperplasia
KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.
She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Typically, one CoolSculpting session will get rid of about 20%-25% of the fat sucked up into the cryolipolysis cup. There can be some discomfort, for instance, when ice crystals are massaged afterward. To ensure patient satisfaction, “you really need to be realistic about what they can expect. It’s likely to be more than one session,” she said.
Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.
She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.
“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.
As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.
Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.
She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Typically, one CoolSculpting session will get rid of about 20%-25% of the fat sucked up into the cryolipolysis cup. There can be some discomfort, for instance, when ice crystals are massaged afterward. To ensure patient satisfaction, “you really need to be realistic about what they can expect. It’s likely to be more than one session,” she said.
Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.
She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.
“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.
As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.
Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
KAUAI, HAWAII – Gentler vacuum pressure seems to reduce the risk of paradoxical adipose hyperplasia after cryolipolysis, according to Suzanne Kilmer, MD, director of the Laser and Skin Surgery Center of Northern California, Sacramento.
She and her colleagues have noticed a reduction with the newer CoolAdvantage applicators from Zeltiq Aesthetics, the manufacturer of CoolSculpting equipment. CoolAdvantage runs colder and with less suction than earlier applicators. “It seems to work equally as well,” but with shorter treatment times, less bruising, and less discomfort. Although paradoxical adipose hyperplasia (PAH) “is incredibly rare, it is something we want to reduce, and we do see decreased incidence with these new applicators,” Dr. Kilmer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.
Typically, one CoolSculpting session will get rid of about 20%-25% of the fat sucked up into the cryolipolysis cup. There can be some discomfort, for instance, when ice crystals are massaged afterward. To ensure patient satisfaction, “you really need to be realistic about what they can expect. It’s likely to be more than one session,” she said.
Another newer option from the manufacturer is the CoolMini applicator for submental fat. Dr. Kilmer generally does two overlapping applications with the CoolMini in the same session, in order to cover as much chin fat as possible. There will be what looks like a stick of butter under the chin when the applicators are removed; it goes away after a few minutes of massage. Patient satisfaction is high, but there can be unveiling of the platysmal bands, which is “something you want to talk to patients about ahead of time,” she said.
She sometimes uses the CoolMini first, followed by the other recently available option for submental fat, deoxycholic acid (Kybella). “We shrink down everything we can with CoolSculpting, and then come back with Kybella to clean up whatever’s left.” Using this approach, patients are injected with less deoxycholic acid, with less inflammation, she said.
“I think you get more fat loss out of a given CoolSculpting treatment than you do with Kybella,” said Dr. Kilmer, who noted that deoxycholic acid is also an option for PAH.
As for going off label with CoolSculpting for jowls, “we’ve done it, and I tell everybody there’s a chance of a 2-3 month palsy. All you are really doing is demyelinating the nerve, not injuring it. If you do liposuction, you actually have a little bit of risk of actually injuring it. You can use a nerve stimulator to map out the nerves beforehand,” she said.
Dr. Kilmer is a consultant for Zeltiq Aesthetics, and an investigator on many of the company’s development trials. She’s also a consultant for Allergan, manufacturer of Kybella, which recently acquired Zeltiq. SDEF/Global Academy for Medical Education and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Aesthetic procedures becoming more popular in skin of color patients
in a presentation at the Caribbean Dermatology Symposium.
In 2015, ethnic minority patients accounted for 25% of aesthetic procedures in the United States, up from 20% in 2010, according to data from the American Society for Aesthetic Plastic Surgery, said Dr. Alexis, chair of dermatology and director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West hospitals in New York.
Chemical peels can be used successfully to treat a range of conditions in skin of color patients, including postinflammatory hyperpigmentation, acne, melasma, textural irregularities, and pseudofolliculitis barbae. They also can be used for skin brightening, said Dr. Alexis, who recommended a chemical peel protocol of salicylic acid, glycolic acid, or Jessner’s every 2-4 weeks. “Consider hydroquinone 4% concurrently to enhance efficacy for treating hyperpigmentation and to prevent postinflammatory hyperpigmentation,” he said. Patients on retinoids should discontinue them for 1 week prior to a chemical peel, he added.
Dr. Alexis shared several treatment pearls to promote successful peels in skin of color patients:
- Salicylic acid: Resist the urge to overapply and “titrate according to patient tolerability.” The endpoint of a salicylic acid peel is white precipitate, not frost; cool compresses can be used for patient comfort and for later removal of the white precipitate.
- Glycolic acid: Stick to a contact time of 2-4 minutes to avoid epidermolysis. “Completely neutralize all areas of application to avoid overpeeling.”
- Trichloroacetic acid (TCA): TCA carries a greater risk of dyspigmentation, and should be reserved for patients who have not been successfully treated with salicylic or glycolic acid; a 10%-15% concentration of TCA, applied conservatively, is recommended.
Regardless of the type of chemical, potential pitfalls of peels in patients of color include using too much product, allowing too long of an application time, and applying the chemical to an inflamed or excoriated area, Dr. Alexis said. Patients who don’t discontinue retinoids before a peel are at increased risk of developing erosions or crusting, he added.
Dr. Alexis disclosed relationships with Allergan, BioPharmX, Dermira, Galderma, Novan, Novartis, RXi, Unilever, and Valeant.
Global Academy and this news organization are owned by the same parent company.
in a presentation at the Caribbean Dermatology Symposium.
In 2015, ethnic minority patients accounted for 25% of aesthetic procedures in the United States, up from 20% in 2010, according to data from the American Society for Aesthetic Plastic Surgery, said Dr. Alexis, chair of dermatology and director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West hospitals in New York.
Chemical peels can be used successfully to treat a range of conditions in skin of color patients, including postinflammatory hyperpigmentation, acne, melasma, textural irregularities, and pseudofolliculitis barbae. They also can be used for skin brightening, said Dr. Alexis, who recommended a chemical peel protocol of salicylic acid, glycolic acid, or Jessner’s every 2-4 weeks. “Consider hydroquinone 4% concurrently to enhance efficacy for treating hyperpigmentation and to prevent postinflammatory hyperpigmentation,” he said. Patients on retinoids should discontinue them for 1 week prior to a chemical peel, he added.
Dr. Alexis shared several treatment pearls to promote successful peels in skin of color patients:
- Salicylic acid: Resist the urge to overapply and “titrate according to patient tolerability.” The endpoint of a salicylic acid peel is white precipitate, not frost; cool compresses can be used for patient comfort and for later removal of the white precipitate.
- Glycolic acid: Stick to a contact time of 2-4 minutes to avoid epidermolysis. “Completely neutralize all areas of application to avoid overpeeling.”
- Trichloroacetic acid (TCA): TCA carries a greater risk of dyspigmentation, and should be reserved for patients who have not been successfully treated with salicylic or glycolic acid; a 10%-15% concentration of TCA, applied conservatively, is recommended.
Regardless of the type of chemical, potential pitfalls of peels in patients of color include using too much product, allowing too long of an application time, and applying the chemical to an inflamed or excoriated area, Dr. Alexis said. Patients who don’t discontinue retinoids before a peel are at increased risk of developing erosions or crusting, he added.
Dr. Alexis disclosed relationships with Allergan, BioPharmX, Dermira, Galderma, Novan, Novartis, RXi, Unilever, and Valeant.
Global Academy and this news organization are owned by the same parent company.
in a presentation at the Caribbean Dermatology Symposium.
In 2015, ethnic minority patients accounted for 25% of aesthetic procedures in the United States, up from 20% in 2010, according to data from the American Society for Aesthetic Plastic Surgery, said Dr. Alexis, chair of dermatology and director of the Skin of Color Center at Mount Sinai St. Luke’s and Mount Sinai West hospitals in New York.
Chemical peels can be used successfully to treat a range of conditions in skin of color patients, including postinflammatory hyperpigmentation, acne, melasma, textural irregularities, and pseudofolliculitis barbae. They also can be used for skin brightening, said Dr. Alexis, who recommended a chemical peel protocol of salicylic acid, glycolic acid, or Jessner’s every 2-4 weeks. “Consider hydroquinone 4% concurrently to enhance efficacy for treating hyperpigmentation and to prevent postinflammatory hyperpigmentation,” he said. Patients on retinoids should discontinue them for 1 week prior to a chemical peel, he added.
Dr. Alexis shared several treatment pearls to promote successful peels in skin of color patients:
- Salicylic acid: Resist the urge to overapply and “titrate according to patient tolerability.” The endpoint of a salicylic acid peel is white precipitate, not frost; cool compresses can be used for patient comfort and for later removal of the white precipitate.
- Glycolic acid: Stick to a contact time of 2-4 minutes to avoid epidermolysis. “Completely neutralize all areas of application to avoid overpeeling.”
- Trichloroacetic acid (TCA): TCA carries a greater risk of dyspigmentation, and should be reserved for patients who have not been successfully treated with salicylic or glycolic acid; a 10%-15% concentration of TCA, applied conservatively, is recommended.
Regardless of the type of chemical, potential pitfalls of peels in patients of color include using too much product, allowing too long of an application time, and applying the chemical to an inflamed or excoriated area, Dr. Alexis said. Patients who don’t discontinue retinoids before a peel are at increased risk of developing erosions or crusting, he added.
Dr. Alexis disclosed relationships with Allergan, BioPharmX, Dermira, Galderma, Novan, Novartis, RXi, Unilever, and Valeant.
Global Academy and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
Nd:YAG laser treatment improves the appearance of facial wrinkles
wrote Eric F. Bernstein, MD, a laser surgeon in private practice in Ardmore, Pa., and his associates.
In the study, two fractionated lasers were each combined with a specially designed “holographic beam-splitting optic” to treat mild to moderate facial wrinkles in 24 patients aged 18-75 years with Fitzpatrick skin types I-VI; 14 patients received five monthly treatments with the 1,064 nm laser, while the other 10 patients received four monthly treatments with the 532 nm laser.
Blinded evaluators assessed images taken at baseline and at 12 weeks after treatment. The evaluators found improvements of greater than 20% in 56.9% of the evaluated images, with no statistically significant difference between the two wavelengths. Of those treated with the 1,064 nm laser, 12 of 14 patients were “satisfied” or “very satisfied”; of those treated with the 532 nm laser, 8 of the 10 were “satisfied” or “very satisfied,” Dr. Bernstein and his colleagues wrote in the Journal of Drugs in Dermatology.
Patients experienced only mild to moderate discomfort during the laser treatment. Side effects were mild and were limited to erythema and edema in almost all patients; fewer than half the patients developed petechiae. Side effects generally resolved within a few days of treatment.
Dr. Bernstein and some of the other authors reported relationships with Syneron Candela, which provided funding for and loaned equipment used in the study.
Source: Bernstein EF et al. J Drugs Dermatol. 2017 Nov 1;16(11):1077-82.
wrote Eric F. Bernstein, MD, a laser surgeon in private practice in Ardmore, Pa., and his associates.
In the study, two fractionated lasers were each combined with a specially designed “holographic beam-splitting optic” to treat mild to moderate facial wrinkles in 24 patients aged 18-75 years with Fitzpatrick skin types I-VI; 14 patients received five monthly treatments with the 1,064 nm laser, while the other 10 patients received four monthly treatments with the 532 nm laser.
Blinded evaluators assessed images taken at baseline and at 12 weeks after treatment. The evaluators found improvements of greater than 20% in 56.9% of the evaluated images, with no statistically significant difference between the two wavelengths. Of those treated with the 1,064 nm laser, 12 of 14 patients were “satisfied” or “very satisfied”; of those treated with the 532 nm laser, 8 of the 10 were “satisfied” or “very satisfied,” Dr. Bernstein and his colleagues wrote in the Journal of Drugs in Dermatology.
Patients experienced only mild to moderate discomfort during the laser treatment. Side effects were mild and were limited to erythema and edema in almost all patients; fewer than half the patients developed petechiae. Side effects generally resolved within a few days of treatment.
Dr. Bernstein and some of the other authors reported relationships with Syneron Candela, which provided funding for and loaned equipment used in the study.
Source: Bernstein EF et al. J Drugs Dermatol. 2017 Nov 1;16(11):1077-82.
wrote Eric F. Bernstein, MD, a laser surgeon in private practice in Ardmore, Pa., and his associates.
In the study, two fractionated lasers were each combined with a specially designed “holographic beam-splitting optic” to treat mild to moderate facial wrinkles in 24 patients aged 18-75 years with Fitzpatrick skin types I-VI; 14 patients received five monthly treatments with the 1,064 nm laser, while the other 10 patients received four monthly treatments with the 532 nm laser.
Blinded evaluators assessed images taken at baseline and at 12 weeks after treatment. The evaluators found improvements of greater than 20% in 56.9% of the evaluated images, with no statistically significant difference between the two wavelengths. Of those treated with the 1,064 nm laser, 12 of 14 patients were “satisfied” or “very satisfied”; of those treated with the 532 nm laser, 8 of the 10 were “satisfied” or “very satisfied,” Dr. Bernstein and his colleagues wrote in the Journal of Drugs in Dermatology.
Patients experienced only mild to moderate discomfort during the laser treatment. Side effects were mild and were limited to erythema and edema in almost all patients; fewer than half the patients developed petechiae. Side effects generally resolved within a few days of treatment.
Dr. Bernstein and some of the other authors reported relationships with Syneron Candela, which provided funding for and loaned equipment used in the study.
Source: Bernstein EF et al. J Drugs Dermatol. 2017 Nov 1;16(11):1077-82.
FROM THE JOURNAL OF DRUGS IN DERMATOLOGY
Set realistic expectations prior to perioral rejuvenation procedures
MIAMI – The success of perioral rejuvenation depends in large part on setting realistic expectations. But there are also tips and tricks to individualizing the technique for each patient that can lead to better outcomes and greater satisfaction – whether patients receive injections into the fine lines above the lip, full-field erbium laser resurfacing, neuromodulator treatment, or a combination approach, according to Joel L. Cohen, MD.
When a patient presents with major lines in the perioral area, an “orange peel” texture, and/or elastotic changes, laser resurfacing can be an appropriate option. “Full field erbium laser resurfacing can give patients a nice improvement of upper lip lines and even a nice contraction of oral commissure,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference.
Although each treatment is individualized to the patient, “I tend to do full field erbium resurfacing around the mouth and eyes, and fractional ablative resurfacing around the rest of the face,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in metropolitan Denver.
More downtime is associated with laser resurfacing compared with fillers or neuromodulator injections, but long-term patient satisfaction, even with improvement in quality of life for some patients (who become less anxious about these lines and more self-confident), can make this approach worthwhile. During his presentation, Dr. Cohen showed photos of many of his treated patients, including one woman whose grandchildren he said had been commenting about the “orange peel texture of her upper lip,” until she completed the resurfacing treatment.
Keep expectations realistic
Dr. Cohen recommended counseling patients about the potential benefits – and the caveats – associated with full-field erbium heavier resurfacing. “Make sure people understand they will look terrible for several days after heavy resurfacing, usually taking about 10-12 days to re-epithelialize,” he said. “We need to tell patients that the perioral area typically manifests more lines than other areas, so we need treat this area differently than just ablative fractional resurfacing in many cases.”
He explained that with heavier resurfacing procedures, it helps to show patients what is expected over the days to weeks in the healing process. They need to understand and see photos that show that the full-field erbium areas will have a yellow fibrinous healing response for the first week or so, which looks very different from the fractional ablative-treated areas (which are more typically red, weepy, and swollen).
He encourages these patients to come back a few days after the procedure to check their healing and review wound-care instructions, especially for patients who have deeper full-field perioral erbium resurfacing (those who are treated with 450-700 microns). Another tip he provided is to have these postresurfacing patients enter/exit through a separate entrance and also sit in a separate cosmetic waiting room at off-hours.
Re-epithelialization generally takes about 10-12 days for most people, with a maximal improvement at approximately 3 months, Dr. Cohen said. “Some patients can see not only significant improvement of upper lip lines, but often a nice contraction of the oral commissure even before fillers are performed to buttress the marionette area and oral commissure,” he said.
With full-field ablative resurfacing in specific areas, rather than simply fractional ablative resurfacing, it is also important to educate patients that some postinflammatory erythema is expected, which, in some cases, may persist for a few months. “In my experience, topical vasoconstrictors don’t seem to help minimize prolonged redness in the full-field erbium areas, but potent topical steroids can be beneficial,” Dr. Cohen said.
More tips for success
Injected local anesthesia is warranted prior to heavier laser resurfacing to keep patients as comfortable as possible. An infraorbital block with an added submucosal/sulcus block with plain lidocaine can be a good approach, he noted. Different perioral and facial areas have different degrees of lines, requiring different laser settings. He prefers to use plain lidocaine perioral blocks, “so that I can theoretically best see the endpoint pinpoint bleeding,” he said, adding that “significant pinpoint bleeding is a good place to stop.”
Typically, he uses a neuromodulator a week or two before full-field perioral erbium resurfacing. “I choose not to give a neuromodulator on the same day as I am concerned about swelling or manipulation of the skin causing unwanted spread to adjacent musculature,” Dr. Cohen said.
Another tip is to take photos with more than one device. “Standardized photos may lose detail of etched lines; we take both iPad and standardized camera system photos,” he said, adding that it is important that clinic staff are proficient at taking proper before-and-after photos, making sure, for example, that the patient does not have confounding makeup or lipstick on for photos, and patient positioning is consistent.
He said it is imperative to emphasize the importance of diligent sun protection for several months after the laser procedure. “Every patient reassures us they use sunscreen, but we often don’t know what sunscreen they are using or how frequently they are using it,” Dr. Cohen said. “If they don’t follow our specific instructions to use a physical block sunscreen, they will significantly increase their risk of developing postinflammatory hyperpigmentation. This caveat applies all year round, and isn’t just for those that go to the beach or play golf, but is also especially important for those patients that ski or hike at higher altitudes.”
Depending on the degree of etched-in lines in the perioral area, one perioral full-field laser resurfacing treatment is generally sufficient for most patients to see significant improvement. For those with more severe etched lines and/or bigger goals for improvement, additional treatments can be performed – but he generally waits about 3 months to see the overall effect of the initial treatment session.
If patients have just a few discrete etched-lines on each side of the upper lip, fillers can be helpful. But, the number and caliber of fine lines on the cutaneous lip limit how much a dermatologist can realistically treat. “So for people with many, many etched-in lines on the cutaneous lip, I explain that fillers are not the right tool for the job – and that they need heavier laser resurfacing.” And those patients really concerned about downtime need to understand that the bruising that can occur with fillers for several days can lead to some degree of social downtime as well.
Options to treat perioral lines not ‘etched in’
Sometimes younger patients, those in their late 20s to early 40s, present with concerns about their perioral appearance. Although they do not have lines at rest yet, they can be unhappy with the muscle columns that appear above their lips with animation that begin to cause lines at rest imprinted in the skin. And many of these women complain that their lipstick bleeds into this area,” Dr. Cohen said. “These patients without etched lines can be treated with a neuromodulator alone to soften the mechanical action of the orbicularis oris muscle,” he pointed out.
Dr. Cohen disclosed having participated in clinical trials and/or having served as a consultant for Merz, Allergan, Galderma, Suneva, Sciton, and Lutronic.
MIAMI – The success of perioral rejuvenation depends in large part on setting realistic expectations. But there are also tips and tricks to individualizing the technique for each patient that can lead to better outcomes and greater satisfaction – whether patients receive injections into the fine lines above the lip, full-field erbium laser resurfacing, neuromodulator treatment, or a combination approach, according to Joel L. Cohen, MD.
When a patient presents with major lines in the perioral area, an “orange peel” texture, and/or elastotic changes, laser resurfacing can be an appropriate option. “Full field erbium laser resurfacing can give patients a nice improvement of upper lip lines and even a nice contraction of oral commissure,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference.
Although each treatment is individualized to the patient, “I tend to do full field erbium resurfacing around the mouth and eyes, and fractional ablative resurfacing around the rest of the face,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in metropolitan Denver.
More downtime is associated with laser resurfacing compared with fillers or neuromodulator injections, but long-term patient satisfaction, even with improvement in quality of life for some patients (who become less anxious about these lines and more self-confident), can make this approach worthwhile. During his presentation, Dr. Cohen showed photos of many of his treated patients, including one woman whose grandchildren he said had been commenting about the “orange peel texture of her upper lip,” until she completed the resurfacing treatment.
Keep expectations realistic
Dr. Cohen recommended counseling patients about the potential benefits – and the caveats – associated with full-field erbium heavier resurfacing. “Make sure people understand they will look terrible for several days after heavy resurfacing, usually taking about 10-12 days to re-epithelialize,” he said. “We need to tell patients that the perioral area typically manifests more lines than other areas, so we need treat this area differently than just ablative fractional resurfacing in many cases.”
He explained that with heavier resurfacing procedures, it helps to show patients what is expected over the days to weeks in the healing process. They need to understand and see photos that show that the full-field erbium areas will have a yellow fibrinous healing response for the first week or so, which looks very different from the fractional ablative-treated areas (which are more typically red, weepy, and swollen).
He encourages these patients to come back a few days after the procedure to check their healing and review wound-care instructions, especially for patients who have deeper full-field perioral erbium resurfacing (those who are treated with 450-700 microns). Another tip he provided is to have these postresurfacing patients enter/exit through a separate entrance and also sit in a separate cosmetic waiting room at off-hours.
Re-epithelialization generally takes about 10-12 days for most people, with a maximal improvement at approximately 3 months, Dr. Cohen said. “Some patients can see not only significant improvement of upper lip lines, but often a nice contraction of the oral commissure even before fillers are performed to buttress the marionette area and oral commissure,” he said.
With full-field ablative resurfacing in specific areas, rather than simply fractional ablative resurfacing, it is also important to educate patients that some postinflammatory erythema is expected, which, in some cases, may persist for a few months. “In my experience, topical vasoconstrictors don’t seem to help minimize prolonged redness in the full-field erbium areas, but potent topical steroids can be beneficial,” Dr. Cohen said.
More tips for success
Injected local anesthesia is warranted prior to heavier laser resurfacing to keep patients as comfortable as possible. An infraorbital block with an added submucosal/sulcus block with plain lidocaine can be a good approach, he noted. Different perioral and facial areas have different degrees of lines, requiring different laser settings. He prefers to use plain lidocaine perioral blocks, “so that I can theoretically best see the endpoint pinpoint bleeding,” he said, adding that “significant pinpoint bleeding is a good place to stop.”
Typically, he uses a neuromodulator a week or two before full-field perioral erbium resurfacing. “I choose not to give a neuromodulator on the same day as I am concerned about swelling or manipulation of the skin causing unwanted spread to adjacent musculature,” Dr. Cohen said.
Another tip is to take photos with more than one device. “Standardized photos may lose detail of etched lines; we take both iPad and standardized camera system photos,” he said, adding that it is important that clinic staff are proficient at taking proper before-and-after photos, making sure, for example, that the patient does not have confounding makeup or lipstick on for photos, and patient positioning is consistent.
He said it is imperative to emphasize the importance of diligent sun protection for several months after the laser procedure. “Every patient reassures us they use sunscreen, but we often don’t know what sunscreen they are using or how frequently they are using it,” Dr. Cohen said. “If they don’t follow our specific instructions to use a physical block sunscreen, they will significantly increase their risk of developing postinflammatory hyperpigmentation. This caveat applies all year round, and isn’t just for those that go to the beach or play golf, but is also especially important for those patients that ski or hike at higher altitudes.”
Depending on the degree of etched-in lines in the perioral area, one perioral full-field laser resurfacing treatment is generally sufficient for most patients to see significant improvement. For those with more severe etched lines and/or bigger goals for improvement, additional treatments can be performed – but he generally waits about 3 months to see the overall effect of the initial treatment session.
If patients have just a few discrete etched-lines on each side of the upper lip, fillers can be helpful. But, the number and caliber of fine lines on the cutaneous lip limit how much a dermatologist can realistically treat. “So for people with many, many etched-in lines on the cutaneous lip, I explain that fillers are not the right tool for the job – and that they need heavier laser resurfacing.” And those patients really concerned about downtime need to understand that the bruising that can occur with fillers for several days can lead to some degree of social downtime as well.
Options to treat perioral lines not ‘etched in’
Sometimes younger patients, those in their late 20s to early 40s, present with concerns about their perioral appearance. Although they do not have lines at rest yet, they can be unhappy with the muscle columns that appear above their lips with animation that begin to cause lines at rest imprinted in the skin. And many of these women complain that their lipstick bleeds into this area,” Dr. Cohen said. “These patients without etched lines can be treated with a neuromodulator alone to soften the mechanical action of the orbicularis oris muscle,” he pointed out.
Dr. Cohen disclosed having participated in clinical trials and/or having served as a consultant for Merz, Allergan, Galderma, Suneva, Sciton, and Lutronic.
MIAMI – The success of perioral rejuvenation depends in large part on setting realistic expectations. But there are also tips and tricks to individualizing the technique for each patient that can lead to better outcomes and greater satisfaction – whether patients receive injections into the fine lines above the lip, full-field erbium laser resurfacing, neuromodulator treatment, or a combination approach, according to Joel L. Cohen, MD.
When a patient presents with major lines in the perioral area, an “orange peel” texture, and/or elastotic changes, laser resurfacing can be an appropriate option. “Full field erbium laser resurfacing can give patients a nice improvement of upper lip lines and even a nice contraction of oral commissure,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference.
Although each treatment is individualized to the patient, “I tend to do full field erbium resurfacing around the mouth and eyes, and fractional ablative resurfacing around the rest of the face,” said Dr. Cohen, an aesthetic dermatologist and Mohs surgeon in private practice in metropolitan Denver.
More downtime is associated with laser resurfacing compared with fillers or neuromodulator injections, but long-term patient satisfaction, even with improvement in quality of life for some patients (who become less anxious about these lines and more self-confident), can make this approach worthwhile. During his presentation, Dr. Cohen showed photos of many of his treated patients, including one woman whose grandchildren he said had been commenting about the “orange peel texture of her upper lip,” until she completed the resurfacing treatment.
Keep expectations realistic
Dr. Cohen recommended counseling patients about the potential benefits – and the caveats – associated with full-field erbium heavier resurfacing. “Make sure people understand they will look terrible for several days after heavy resurfacing, usually taking about 10-12 days to re-epithelialize,” he said. “We need to tell patients that the perioral area typically manifests more lines than other areas, so we need treat this area differently than just ablative fractional resurfacing in many cases.”
He explained that with heavier resurfacing procedures, it helps to show patients what is expected over the days to weeks in the healing process. They need to understand and see photos that show that the full-field erbium areas will have a yellow fibrinous healing response for the first week or so, which looks very different from the fractional ablative-treated areas (which are more typically red, weepy, and swollen).
He encourages these patients to come back a few days after the procedure to check their healing and review wound-care instructions, especially for patients who have deeper full-field perioral erbium resurfacing (those who are treated with 450-700 microns). Another tip he provided is to have these postresurfacing patients enter/exit through a separate entrance and also sit in a separate cosmetic waiting room at off-hours.
Re-epithelialization generally takes about 10-12 days for most people, with a maximal improvement at approximately 3 months, Dr. Cohen said. “Some patients can see not only significant improvement of upper lip lines, but often a nice contraction of the oral commissure even before fillers are performed to buttress the marionette area and oral commissure,” he said.
With full-field ablative resurfacing in specific areas, rather than simply fractional ablative resurfacing, it is also important to educate patients that some postinflammatory erythema is expected, which, in some cases, may persist for a few months. “In my experience, topical vasoconstrictors don’t seem to help minimize prolonged redness in the full-field erbium areas, but potent topical steroids can be beneficial,” Dr. Cohen said.
More tips for success
Injected local anesthesia is warranted prior to heavier laser resurfacing to keep patients as comfortable as possible. An infraorbital block with an added submucosal/sulcus block with plain lidocaine can be a good approach, he noted. Different perioral and facial areas have different degrees of lines, requiring different laser settings. He prefers to use plain lidocaine perioral blocks, “so that I can theoretically best see the endpoint pinpoint bleeding,” he said, adding that “significant pinpoint bleeding is a good place to stop.”
Typically, he uses a neuromodulator a week or two before full-field perioral erbium resurfacing. “I choose not to give a neuromodulator on the same day as I am concerned about swelling or manipulation of the skin causing unwanted spread to adjacent musculature,” Dr. Cohen said.
Another tip is to take photos with more than one device. “Standardized photos may lose detail of etched lines; we take both iPad and standardized camera system photos,” he said, adding that it is important that clinic staff are proficient at taking proper before-and-after photos, making sure, for example, that the patient does not have confounding makeup or lipstick on for photos, and patient positioning is consistent.
He said it is imperative to emphasize the importance of diligent sun protection for several months after the laser procedure. “Every patient reassures us they use sunscreen, but we often don’t know what sunscreen they are using or how frequently they are using it,” Dr. Cohen said. “If they don’t follow our specific instructions to use a physical block sunscreen, they will significantly increase their risk of developing postinflammatory hyperpigmentation. This caveat applies all year round, and isn’t just for those that go to the beach or play golf, but is also especially important for those patients that ski or hike at higher altitudes.”
Depending on the degree of etched-in lines in the perioral area, one perioral full-field laser resurfacing treatment is generally sufficient for most patients to see significant improvement. For those with more severe etched lines and/or bigger goals for improvement, additional treatments can be performed – but he generally waits about 3 months to see the overall effect of the initial treatment session.
If patients have just a few discrete etched-lines on each side of the upper lip, fillers can be helpful. But, the number and caliber of fine lines on the cutaneous lip limit how much a dermatologist can realistically treat. “So for people with many, many etched-in lines on the cutaneous lip, I explain that fillers are not the right tool for the job – and that they need heavier laser resurfacing.” And those patients really concerned about downtime need to understand that the bruising that can occur with fillers for several days can lead to some degree of social downtime as well.
Options to treat perioral lines not ‘etched in’
Sometimes younger patients, those in their late 20s to early 40s, present with concerns about their perioral appearance. Although they do not have lines at rest yet, they can be unhappy with the muscle columns that appear above their lips with animation that begin to cause lines at rest imprinted in the skin. And many of these women complain that their lipstick bleeds into this area,” Dr. Cohen said. “These patients without etched lines can be treated with a neuromodulator alone to soften the mechanical action of the orbicularis oris muscle,” he pointed out.
Dr. Cohen disclosed having participated in clinical trials and/or having served as a consultant for Merz, Allergan, Galderma, Suneva, Sciton, and Lutronic.
EXPERT ANALYSIS FROM ODAC 2018
Using oral and topical cosmeceuticals to prevent and treat skin aging, Part II
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
6. Mech Ageing Dev. 1986 Jul;35(2):185-98.
7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
6. Mech Ageing Dev. 1986 Jul;35(2):185-98.
7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
This month’s column resumes my review of prevention and treatment strategies for aging skin using oral and topical cosmeceutical agents.
Preventing and treating inflammation
Skin aging can result from inflammation through several mechanisms, including the formation of reactive oxygen species. Inflammation itself arises from myriad etiologic pathways, with multiple inflammatory mediators potentially involved, including histamines, cytokines, eicosanoids (for example, prostaglandins, thromboxanes, and leukotrienes), complement cascade components, kinins, fibrinopeptide enzymes, nuclear factor–kappa B, and free radicals.
Topically applied argan oil, caffeine, chamomile, feverfew, green tea, licorice extract, aloe, linoleic acid (found in high concentrations in argan oil and safflower oil), and niacinamide are among the anti-inflammatory ingredients that have been used successfully in topical skin care to reduce inflammation. The Food and Drug Administration does not allow cosmetics to make “anti-inflammatory” claims. For this reason, these products will state they have “soothing” effects or imply they improve of redness.
Oral polypodium leucotomos has been demonstrated to suppress the effect of UV radiation on COX-2 expression.2 Also, glycolic acid has exhibited the capacity to inhibit COX-2 signaling and other inflammatory mediators.3
Preventing and treating glycation
Glycation is produced by the Maillard reaction, a chemical reaction – particularly well known in cooking – between an amino acid and a sugar molecule that typically requires heat. This reaction was first described by Louis Camille Maillard in 1912 when he noted that amino acids can react with sugar to yield brown or golden-brown substances. It took until the 1980s for scientists to understand the importance of glycation in health.
When glycation occurs, sugar molecules attach to proteins, creating cross-linked proteins known as advanced glycation end products (or AGEs) and causing a series of chemical reactions. Glycation occurs in collagen fibers and results in the formation of cross-links that bind collagen fibers to each other, which leaves the skin stiffer. Glycosylated collagen is believed to be a factor in the appearance of aged skin.4 Glycation also can affect elastin: Recent research suggests that glycation can engender elastosis, which is elastin that is abnormally clumped together and presents more frequently in aged skin.
Several antiaging skin care products claim to treat glycation, but – unfortunately – glycation is not a reversible reaction. It must be prevented in the first place. Some studies suggest that antioxidants can prevent glycation, but it is more likely that they just divert the process down a different pathway that still leads to glycation. Reducing serum glucose levels is the optimum method of preventing glycation.5 Dietary intervention and oral metformin are recommended for lowering glycation.
REVERSING SKIN CELL AGING
Epidermal keratinocytes in aging
Young basal stem cells synthesize a plethora of new keratinocytes at a pace that leads to fast cell turnover and vigorous production of protective epidermal constituents. Old keratinocytes display less energy, show reduced responsiveness to cellular signals, and do not synthesize these protective components.6,7 Keratinocyte stem cell function declines over time while damage accumulates, as seen in a diminished response to growth factors, decreased keratinization, and impaired function.8
Dermal fibroblasts in cutaneous aging
Young fibroblasts produce key cellular constituents, including collagen, elastin, hyaluronic acid, and heparan sulfate. This production declines in older fibroblasts. Like aging keratinocytes, old fibroblasts lose energy and responsiveness to growth factors and other cellular signals.6,7
Rejuvenating aged skin with cosmeceuticals
Gene expression, growth factors, cytokines, chemokines, and receptor activation guide the function of keratinocytes and fibroblasts. To reverse or slow cellular skin aging, old keratinocytes and fibroblasts must be galvanized to respond to such signals or the signals must be enhanced.
Stimulating old keratinocytes and fibroblasts
Essential steps in stimulating aged keratinocytes and fibroblasts include: activating gene expression, adding growth factors, activating cytokines and chemokines, turning on receptors, and making cells more responsive to signals.
Influencing gene expression
Retinoids are known to affect collagen genes and increase activity of procollagen genes, thereby reducing the production of collagenase. Many studies have shown the efficacy of retinoids in treating aged skin and preventing cutaneous aging in both areas frequently exposed to the sun but also those that aren’t.9,10 Prescription retinoids (tretinoin, adapalene, tazarotene) and over-the-counter retinoids (retinol) are first-line options to treat and prevent aging by stimulating old keratinocytes and fibroblasts.10,11 However, exposing retinoic acid receptors to retinoids almost invariably leads to erythema and flaking in the first few weeks. Therefore, retinoids should be titrated slowly. Note that retinoid esters, such as retinyl palmitate and retinyl linoleate, do not penetrate well into the dermis;12 they also are not as effective as retinol, tretinoin, adapalene, and tazarotene. Compliance with retinoids is always an issue with patients. They should receive printed educational material about how to begin use and why it is important to use these products consistently.
Growth factors
The use of cosmetic formulations that contain growth factors can contribute to skin rejuvenation. There are various types of growth factors that have the capacity to stimulate old keratinocytes and fibroblasts to enhance function.17 Growth factors, which are inactive or vulnerable to degradation in their native, soluble form, can directly energize genes or act as a signaling mechanism. To exert their quintessential functions, growth factors must be transferred to the correct receptor site in order for the cell to respond to their signal.18
Heparan sulfate
Heparan sulfate (HS) plays a primary role in cell-to-cell communications. It increases cellular response to growth factors by facilitating the response of old, lazy fibroblasts to the cellular signals.18 HS binds, stores, and protects growth factors, which allows them to complete movement to their targets, and then presents them to the appropriate binding site.18,19 A topically applied analogue of HS has been demonstrated to rejuvenate aged skin.20
Stem cells
Stem cells included and pointedly marketed in cosmeceutical products are usually plant derived, are too large to penetrate the stratum corneum, display short shelf lives, and do not behave as human stem cells would. As a result, stem cells in cosmeceutical agents are essentially useless.
However, novel technologies have revealed ingredients that can incite native stem cells to repopulate the epidermis and dermis with young cells. Stem cells in skin include basal stem cells and 10 varieties of hair follicle stem cells. The LGR6+ hair follicle cells play a pivotal role in repopulating the epidermis after wounding has occurred.21,22 Aesthetic physicians have known for several years that inducing skin wounding with lasers, needles, and acidic peels leads to improvement in its appearance. Researchers have provided new data showing that wounding the skin prompts LGR6+ stem cells to repopulate the epidermis. Once wounding occurs, neutrophils release the peptide defensin, which stimulates the LGR6+ stem cells to repopulate the epidermis.23 Topical defensin that has been formulated to penetrate into hair follicles, where the LGR6+ stem cells reside, has been demonstrated to render a smoother, more youthful appearance to the skin.
Conclusion
It is important for practitioners to identify patients at risk for premature skin aging as early as possible and start them on an appropriate and consistent skin care regimen. This typically will include at least a daily sunscreen with an SPF 15 or higher, a nightly topical retinoid, and oral and topical antioxidants. The patient’s additional skin type proclivities (for example, dryness, inflammation, melanocyte activity) should guide the physician as to how to combine these baseline product types with cleansers, moisturizers, and formulations with hydroxy acids, growth factors, heparan sulfate, and defensin.
Several studies have revealed that patients exhibit poor compliance with recommended regimens.24 Informing patients about the need for skin protection and providing printed instructions can help to improve compliance.25 This can promote healthy lifestyle habits and compliance with scientifically proven antiaging therapies.
Dr. Baumann is a private practice dermatologist, researcher, author, and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002) and “Cosmeceuticals and Cosmetic Ingredients” (New York: McGraw-Hill, 2014); she also authored a New York Times Best Seller for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance Therapeutics. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.
1. Arch Dermatol Res. 2010 Jan;302(1):5-17.
2. Am J Pathol. 2009 Nov;175(5):1952-61.
3. J Dermatol Sci. 2017 Jun;86(3):238-48.
4. Eur J Dermatol. 2007 Jan-Feb;17(1):12-20.
5. “Advanced Glycation End Products (AGEs): Emerging Mediators of Skin Aging,” in Textbook of Aging Skin (Berlin: Springer, 2017, pp. 1675-86).
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7. Exp Cell Res. 1996 Sep 15;227(2):252-5.
8. J Cutan Pathol. 2003 Jul;30(6):351-7.
9. PLoS One. 2015 Feb 6;10(2):e0117491.
10. Arch Dermatol. 2007 May;143(5):606-12.
11. JAMA. 1988 Jan 22-29;259(4):527-32.
12. J Invest Dermatol. 1997 Sep;109(3):301-5.
13. J Am Acad Dermatol. 1996 Feb;34(2 Pt 1):187-95.
14. J Am Acad Dermatol. 1996 Sep;35(3 Pt 1):388-91.
15. Dermatol Surg. 2001 May;27(5):429-33.
16. J Invest Dermatol. 1994 Aug;103(2):228-32.
17. Clin Cosmet Investig Dermatol. 2016 Nov 9;9:411-9.
18. Chem Biol Drug Des. 2008 Dec;72(6):455-82.
19. Front Immunol. 2013 Dec 18;4:470.
20. J Drugs Dermatol. 2015 Jul;14(7):669-74.
21. Science. 2010 Mar 12;327(5971):1385-9.
22. Plast Reconstr Surg. 2014 Mar;133(3):579-90.
23. Plast Reconstr Surg. 2013 Nov;132(5):1159-71.
24. J Am Acad Dermatol. 2008 Jul;59(1):27-33.
25. J Am Acad Dermatol. 2013 Mar;68(3):364.e1-10.
Literature review: Cryolipolysis safe, effective for reducing submental fat
Cryolipolysis is a safe and effective noninvasive treatment for reducing submental fat, according to a review of several published studies.
In a review of four clinical trials and one case series, which involved a total of 101 patients, , reported Shari R. Lipner, MD, of the department of dermatology at Cornell University, New York.
In 2015, the Food and Drug Administration cleared a cryolipolysis device for use in the submental area.
The literature review was performed in May 2017 using Pubmed, EMBASE, Web of Science, and CINAHL databases, searching for the terms cryolipolysis, submental, and paradoxical adipose hyperplasia. Non-English studies were excluded.
The studies included an open-label prospective multicenter trial of 60 patients who underwent cryolipolysis for submental fat reduction once or twice at –10°C for 60 minutes, which found that in 58 evaluable patients, blinded independent reviewers correctly identified baseline photos in 91.4% of cases (P less than .0001). Ultrasound, used to evaluate 57 patients, determined the mean fat layer reduction was 2.0 mm or 20% (ranging from an increase of 2.0 mm to a reduction of –5.9 mm; P less than .0001). Side effects included erythema, edema, bruising, and numbness, which resolved by week 12. Additionally, 83% of the 60 patients were satisfied with the results.
In another study, a prospective nonrandomized study that evaluated overlapping cryolipolysis applications on different visits in 14 patients, pretreatment and post-treatment photographs were correctly identified by blinded independent reviewers 81% of the time (95% confidence interval, 65.9%-91.4%; P = .02). In addition, the mean fat layer reduction, as measured with skin-fold calipers, was 2.3 mm (95% CI, 1.9-2.7 mm; P less than .001), and 93% of the patients were satisfied with the results.
A prospective nonrandomized single-center open-label study of 15 Hispanic patients evaluated cryolipolysis applied to the submental area at two different temperatures (–12°C for 45 minutes and –15°C for 30 minutes) with treatments given 10 weeks apart. The mean reduction in submental fat, as measured by calipers, was 33%, with no significant difference between the two. Blinded physicians correctly identified pre- and post- treatment photos in 60% of cases, and 80% of the patients said they “were satisfied or very satisfied” with the results, according to Dr. Lipner’s review, published online in the Journal of Cosmetic Dermatology.
All studies reported adverse side effects, most commonly erythema, which resolved within weeks of treatment, she wrote. To date, she noted, no cases of mandibular nerve injury or paradoxical adipose hyperplasia have been reported after cryolipolysis for submental fat.
Dr. Lipner referred to early trials in humans found that cryolipolysis was safe and effective for treatment of the back, arms, and chest. Additional trials found no significant changes in lipids or liver function at 1, 4, and 12 weeks’ follow-up when patients were treated for fat in the flanks and lower abdomen.
The results of the literature review suggest that cryolipolysis is safe and effective for submental fat, Dr. Lipner wrote. Appropriate patient selection is important and “patients should be counseled on clinical improvement in the submental contour, number of sessions necessary, side effects, downtime, and cost,” she noted. Liposuction is still the gold standard for removal of large fat deposits, and although cryolipolysis can reduce submental fat, “it may also worsen the appearance on the neck by making platysmal banding or skin imperfections more obvious,” she added.
Dr. Lipner did not report any relevant disclosures. No funding source was provided.
SOURCE: J Cosmet Dermatol. 2018 Jan 17. doi: 10.1111/jocd.12495.
Cryolipolysis is a safe and effective noninvasive treatment for reducing submental fat, according to a review of several published studies.
In a review of four clinical trials and one case series, which involved a total of 101 patients, , reported Shari R. Lipner, MD, of the department of dermatology at Cornell University, New York.
In 2015, the Food and Drug Administration cleared a cryolipolysis device for use in the submental area.
The literature review was performed in May 2017 using Pubmed, EMBASE, Web of Science, and CINAHL databases, searching for the terms cryolipolysis, submental, and paradoxical adipose hyperplasia. Non-English studies were excluded.
The studies included an open-label prospective multicenter trial of 60 patients who underwent cryolipolysis for submental fat reduction once or twice at –10°C for 60 minutes, which found that in 58 evaluable patients, blinded independent reviewers correctly identified baseline photos in 91.4% of cases (P less than .0001). Ultrasound, used to evaluate 57 patients, determined the mean fat layer reduction was 2.0 mm or 20% (ranging from an increase of 2.0 mm to a reduction of –5.9 mm; P less than .0001). Side effects included erythema, edema, bruising, and numbness, which resolved by week 12. Additionally, 83% of the 60 patients were satisfied with the results.
In another study, a prospective nonrandomized study that evaluated overlapping cryolipolysis applications on different visits in 14 patients, pretreatment and post-treatment photographs were correctly identified by blinded independent reviewers 81% of the time (95% confidence interval, 65.9%-91.4%; P = .02). In addition, the mean fat layer reduction, as measured with skin-fold calipers, was 2.3 mm (95% CI, 1.9-2.7 mm; P less than .001), and 93% of the patients were satisfied with the results.
A prospective nonrandomized single-center open-label study of 15 Hispanic patients evaluated cryolipolysis applied to the submental area at two different temperatures (–12°C for 45 minutes and –15°C for 30 minutes) with treatments given 10 weeks apart. The mean reduction in submental fat, as measured by calipers, was 33%, with no significant difference between the two. Blinded physicians correctly identified pre- and post- treatment photos in 60% of cases, and 80% of the patients said they “were satisfied or very satisfied” with the results, according to Dr. Lipner’s review, published online in the Journal of Cosmetic Dermatology.
All studies reported adverse side effects, most commonly erythema, which resolved within weeks of treatment, she wrote. To date, she noted, no cases of mandibular nerve injury or paradoxical adipose hyperplasia have been reported after cryolipolysis for submental fat.
Dr. Lipner referred to early trials in humans found that cryolipolysis was safe and effective for treatment of the back, arms, and chest. Additional trials found no significant changes in lipids or liver function at 1, 4, and 12 weeks’ follow-up when patients were treated for fat in the flanks and lower abdomen.
The results of the literature review suggest that cryolipolysis is safe and effective for submental fat, Dr. Lipner wrote. Appropriate patient selection is important and “patients should be counseled on clinical improvement in the submental contour, number of sessions necessary, side effects, downtime, and cost,” she noted. Liposuction is still the gold standard for removal of large fat deposits, and although cryolipolysis can reduce submental fat, “it may also worsen the appearance on the neck by making platysmal banding or skin imperfections more obvious,” she added.
Dr. Lipner did not report any relevant disclosures. No funding source was provided.
SOURCE: J Cosmet Dermatol. 2018 Jan 17. doi: 10.1111/jocd.12495.
Cryolipolysis is a safe and effective noninvasive treatment for reducing submental fat, according to a review of several published studies.
In a review of four clinical trials and one case series, which involved a total of 101 patients, , reported Shari R. Lipner, MD, of the department of dermatology at Cornell University, New York.
In 2015, the Food and Drug Administration cleared a cryolipolysis device for use in the submental area.
The literature review was performed in May 2017 using Pubmed, EMBASE, Web of Science, and CINAHL databases, searching for the terms cryolipolysis, submental, and paradoxical adipose hyperplasia. Non-English studies were excluded.
The studies included an open-label prospective multicenter trial of 60 patients who underwent cryolipolysis for submental fat reduction once or twice at –10°C for 60 minutes, which found that in 58 evaluable patients, blinded independent reviewers correctly identified baseline photos in 91.4% of cases (P less than .0001). Ultrasound, used to evaluate 57 patients, determined the mean fat layer reduction was 2.0 mm or 20% (ranging from an increase of 2.0 mm to a reduction of –5.9 mm; P less than .0001). Side effects included erythema, edema, bruising, and numbness, which resolved by week 12. Additionally, 83% of the 60 patients were satisfied with the results.
In another study, a prospective nonrandomized study that evaluated overlapping cryolipolysis applications on different visits in 14 patients, pretreatment and post-treatment photographs were correctly identified by blinded independent reviewers 81% of the time (95% confidence interval, 65.9%-91.4%; P = .02). In addition, the mean fat layer reduction, as measured with skin-fold calipers, was 2.3 mm (95% CI, 1.9-2.7 mm; P less than .001), and 93% of the patients were satisfied with the results.
A prospective nonrandomized single-center open-label study of 15 Hispanic patients evaluated cryolipolysis applied to the submental area at two different temperatures (–12°C for 45 minutes and –15°C for 30 minutes) with treatments given 10 weeks apart. The mean reduction in submental fat, as measured by calipers, was 33%, with no significant difference between the two. Blinded physicians correctly identified pre- and post- treatment photos in 60% of cases, and 80% of the patients said they “were satisfied or very satisfied” with the results, according to Dr. Lipner’s review, published online in the Journal of Cosmetic Dermatology.
All studies reported adverse side effects, most commonly erythema, which resolved within weeks of treatment, she wrote. To date, she noted, no cases of mandibular nerve injury or paradoxical adipose hyperplasia have been reported after cryolipolysis for submental fat.
Dr. Lipner referred to early trials in humans found that cryolipolysis was safe and effective for treatment of the back, arms, and chest. Additional trials found no significant changes in lipids or liver function at 1, 4, and 12 weeks’ follow-up when patients were treated for fat in the flanks and lower abdomen.
The results of the literature review suggest that cryolipolysis is safe and effective for submental fat, Dr. Lipner wrote. Appropriate patient selection is important and “patients should be counseled on clinical improvement in the submental contour, number of sessions necessary, side effects, downtime, and cost,” she noted. Liposuction is still the gold standard for removal of large fat deposits, and although cryolipolysis can reduce submental fat, “it may also worsen the appearance on the neck by making platysmal banding or skin imperfections more obvious,” she added.
Dr. Lipner did not report any relevant disclosures. No funding source was provided.
SOURCE: J Cosmet Dermatol. 2018 Jan 17. doi: 10.1111/jocd.12495.
FROM THE JOURNAL OF COSMETIC DERMATOLOGY
Key clinical point: Cryolipolysis appears to be a safe, effective noninvasive treatment for submental fat.
Major finding: Endpoints evaluating the effects of the cooling technique on submental fat included evaluations of blinded patient photos by blinded reviewers, who, in one study, correctly identified baseline photos in 91.4% of cases (P less than .0001).
Data source: A literature review of four clinical trials and one case series of a total of 101 patients who underwent cryolipolysis for reducing submental fat.
Disclosures: The author did not report any relevant disclosures. No funding source was provided.
Source: Cosmet Dermatol. 2018 Jan 17. doi: 10.1111/jocd.12495.
Facial exercises improved appearance in small study of middle-aged women
The role of skin laxity and substructural fat and muscle loss in the appearance of facial aging has been recognized already, and there has been interest within the nonmedical community regarding use of facial exercise to improve appearance, Murad Alam, MD, of Northwestern University, Chicago, and his colleagues wrote in a research letter published in JAMA Dermatology.
The researchers recruited healthy women aged 40-65 years with some photodamage to the face and an interest in facial exercises. After two 90-minute, in-person training sessions with a certified instructor, the participants were asked to perform a 30-minute facial exercise session daily for 8 weeks at home, followed by sessions every other day during weeks 9-20. Sixteen patients completed the full 20-week study.
Two blinded physicians used validated assessment scales to compare photographs of the participants taken at the beginning and end of the 20-week period. Facial exercise was associated with an improved mean upper-cheek fullness score, compared with baseline (1.1 vs. 1.8, respectively; P = .003), and an improved mean lower-cheek fullness score, compared with baseline (0.9 vs. 1.6; P = .003).
In addition, blinded physicians’ estimates of the women’s ages decreased significantly: The estimates dropped from an average of 51 years at baseline to an average of 49 years after the women completed the 20 weeks of facial exercises (P = .002), Dr. Alam and his associates reported.
The study was limited by several factors, including its small sample size, the lack of a control group, and a self-selected population that may have been especially motivated to follow the exercise routine, the researchers noted.
However, the results suggest that the cause for improvements in appearance as a result of the exercises “may be exercise-actuated hypertrophy of cheek and other muscles,” they said. “Further research is warranted to isolate the causes and effects of exercise-related changes and to assess the generalizability of these findings,” Dr. Alam and his associates concluded.
The study was supported by research funds from the department of dermatology at Northwestern University. Dr. Alam disclosed serving as a consultant for Amway and Leo Pharma and has served as an investigator on studies supported in part by Allergan, Medicis Pharmaceutical, BioForm Medical, and Ulthera.
SOURCE: Alam M et al. JAMA Dermatol. 2018 Jan 3. doi: 10.1001/jamadermatol.2017.5142
The role of skin laxity and substructural fat and muscle loss in the appearance of facial aging has been recognized already, and there has been interest within the nonmedical community regarding use of facial exercise to improve appearance, Murad Alam, MD, of Northwestern University, Chicago, and his colleagues wrote in a research letter published in JAMA Dermatology.
The researchers recruited healthy women aged 40-65 years with some photodamage to the face and an interest in facial exercises. After two 90-minute, in-person training sessions with a certified instructor, the participants were asked to perform a 30-minute facial exercise session daily for 8 weeks at home, followed by sessions every other day during weeks 9-20. Sixteen patients completed the full 20-week study.
Two blinded physicians used validated assessment scales to compare photographs of the participants taken at the beginning and end of the 20-week period. Facial exercise was associated with an improved mean upper-cheek fullness score, compared with baseline (1.1 vs. 1.8, respectively; P = .003), and an improved mean lower-cheek fullness score, compared with baseline (0.9 vs. 1.6; P = .003).
In addition, blinded physicians’ estimates of the women’s ages decreased significantly: The estimates dropped from an average of 51 years at baseline to an average of 49 years after the women completed the 20 weeks of facial exercises (P = .002), Dr. Alam and his associates reported.
The study was limited by several factors, including its small sample size, the lack of a control group, and a self-selected population that may have been especially motivated to follow the exercise routine, the researchers noted.
However, the results suggest that the cause for improvements in appearance as a result of the exercises “may be exercise-actuated hypertrophy of cheek and other muscles,” they said. “Further research is warranted to isolate the causes and effects of exercise-related changes and to assess the generalizability of these findings,” Dr. Alam and his associates concluded.
The study was supported by research funds from the department of dermatology at Northwestern University. Dr. Alam disclosed serving as a consultant for Amway and Leo Pharma and has served as an investigator on studies supported in part by Allergan, Medicis Pharmaceutical, BioForm Medical, and Ulthera.
SOURCE: Alam M et al. JAMA Dermatol. 2018 Jan 3. doi: 10.1001/jamadermatol.2017.5142
The role of skin laxity and substructural fat and muscle loss in the appearance of facial aging has been recognized already, and there has been interest within the nonmedical community regarding use of facial exercise to improve appearance, Murad Alam, MD, of Northwestern University, Chicago, and his colleagues wrote in a research letter published in JAMA Dermatology.
The researchers recruited healthy women aged 40-65 years with some photodamage to the face and an interest in facial exercises. After two 90-minute, in-person training sessions with a certified instructor, the participants were asked to perform a 30-minute facial exercise session daily for 8 weeks at home, followed by sessions every other day during weeks 9-20. Sixteen patients completed the full 20-week study.
Two blinded physicians used validated assessment scales to compare photographs of the participants taken at the beginning and end of the 20-week period. Facial exercise was associated with an improved mean upper-cheek fullness score, compared with baseline (1.1 vs. 1.8, respectively; P = .003), and an improved mean lower-cheek fullness score, compared with baseline (0.9 vs. 1.6; P = .003).
In addition, blinded physicians’ estimates of the women’s ages decreased significantly: The estimates dropped from an average of 51 years at baseline to an average of 49 years after the women completed the 20 weeks of facial exercises (P = .002), Dr. Alam and his associates reported.
The study was limited by several factors, including its small sample size, the lack of a control group, and a self-selected population that may have been especially motivated to follow the exercise routine, the researchers noted.
However, the results suggest that the cause for improvements in appearance as a result of the exercises “may be exercise-actuated hypertrophy of cheek and other muscles,” they said. “Further research is warranted to isolate the causes and effects of exercise-related changes and to assess the generalizability of these findings,” Dr. Alam and his associates concluded.
The study was supported by research funds from the department of dermatology at Northwestern University. Dr. Alam disclosed serving as a consultant for Amway and Leo Pharma and has served as an investigator on studies supported in part by Allergan, Medicis Pharmaceutical, BioForm Medical, and Ulthera.
SOURCE: Alam M et al. JAMA Dermatol. 2018 Jan 3. doi: 10.1001/jamadermatol.2017.5142
FROM JAMA DERMATOLOGY
Key clinical point: A 20-week program of facial exercise significantly improved facial fullness and perceived age among women aged 40-65 years.
Major finding: Fullness of the upper and lower cheek significantly improved from baseline after the exercise program, based on a validated scale.
Data source: The data come from a study of 27 women aged 40-65 years.
Disclosures: The study was supported by research funds from the department of dermatology at Northwestern University. Dr. Alam disclosed serving as a consultant for Amway and LEO Pharma and has served as an investigator on studies supported in part by Allergan, Medicis Pharmaceutical, BioForm Medical, and Ulthera.
Source: Alam M et al. JAMA Dermatol. 2018 Jan 3. doi: 10.1001/jamadermatol.2017.5142.
Light therapy offers brighter future for scar patients
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
Current treatment with available light-based devices, notably ablative fractional resurfacing, can greatly improve quality of life for patients struggling with scars, according to Kristen Kelly, MD, of the University of California, Irvine.
Using multiple devices, and combining devices with other therapies, are among the strategies that can improve pain and function in these patients, she said in a presentation at Skin Disease Education Foundation’s annual Las Vegas Dermatology Seminar.
Dr. Kelly recommends “a CO2 laser or an Er:YAG [erbium-doped YAG],” as AFR options for scar treatment. The Er:YAG is less painful, but may cause bleeding, she noted.
Tips for a scar treatment protocol with AFR include low density and treating the entire scar plus a 1-2 mm rim, Dr. Kelly said. AFR treatment of scars can start in some cases soon after an injury, but it depends on the cause of the scar and treatment timing is controversial, especially for burn scars, she said. Dr. Kelly outlined a plan of treatment every 2-3 months, with the option of adding triamcinolone suspension immediately after the AFR treatment, she noted.
Other medications used after AFR to improve results include 5-fluorouracil, bimatoprost, and poly-L-lactic acid. However, “you should only consider this for medications that you would safely inject into the skin or bloodstream,” she emphasized.
Combining AFR with other devices can improve results, depending on the type of scar, said Dr. Kelly. Atrophic scars may be treated with AFR or NAFR, while red atrophic scars may improve with a combination AFR or NAFR and a pulsed dye laser, she said. For red hypertrophic scars, consider a combination of AFR plus a steroid combined with a pulsed dye laser, she added.
When embarking on a scar treatment plan, be sure to define goals and remind patients that scars can be “improved but not removed,” said Dr. Kelly. “Laser therapy is often not monotherapy,” she added. A surgical revision, such as a Z-plasty, and the use of physical and occupational therapy also can improve results and improve quality of life for patients, she said.
Dr. Kelly disclosed relationships with multiple companies including Allergan, MundiPharma, Syneron Candela, Light Sciences Oncology, Novartis, Sciton, and ThermiRF.
SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF LAS VEGAS DERMATOLOGY SEMINAR
FDA issues alert on illegal silicone injections
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
The Food and Drug Administration has issued a warning regarding the use of injectable silicone or other products illegally marketed as dermal fillers for body contouring.
“We have significant concerns with unsafe injectable silicone that’s being marketed for body contouring by unlicensed providers,” FDA Commissioner Scott Gottlieb, MD, said in a statement on Nov. 14. “We’ve seen serious adverse events result from products, which are sometimes industrial-grade silicone, being used for these unapproved medical purposes,” he said.
Simply injecting silicone into various parts of the body for contouring purposes is not approved by the FDA. Side effects of such a procedure can occur immediately, or may appear after days, weeks, months, or years, according to the statement. Side effects include pain, scarring, disfigurement, life-threatening embolism, stroke, or infection, the FDA emphasized.
The FDA continues to take action against unlicensed practitioners found guilty of treating patients with unapproved silicone for body contouring. “In addition to prosecuting the criminals who take advantage of consumers, the FDA is taking action to educate consumers in order to prevent the serious injuries resulting from these injections,” Melinda Plaisier, associate commissioner for regulatory affairs at the FDA, said in the statement. “We hope to raise public awareness about the short- and long-term risks of injecting silicone directly into the body, and encourage consumers to choose FDA-approved products and licensed providers when considering any type of cosmetic enhancement,” she said.
The FDA will continue to monitor adverse event reports related to silicone, and encourages clinicians or consumers with information about the use of injectable silicone by unlicensed providers to use the “Report Suspected Criminal Activity” form on the FDA website to report those cases.
Stem cells spark successful skin regeneration
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
Junctional epidermolysis bullosa is a genetic disease characterized by chronic skin wounds, blisters, and erosions. The chronic wounds not only increase a patient’s risk of skin cancer, they also can cause itching, pain, limited mobility, and poor quality of life, wrote Tobias Hirsch, MD, of BG University Hospital Bergmannsheil, Bochum, Germany, and colleagues (Nature. 2017. doi: 10.1038/nature24487). There is no cure for the disease, and more than 40% of patients die prior to adolescence.
Previous studies have shown that epidermal stem cells can be used to repair a damaged epidermis, they noted. However, the technique has been criticized for being insufficient to treat the large lesions common to this disease.
The researchers described the case of a 7-year-old boy who was admitted to a children’s hospital in Germany in June 2015 with junctional epidermolysis bullosa so severe that approximately 80% of his total body surface area was affected. The patient had a genetic mutation that had resulted in blisters on much of his body since birth. Approximately 6 weeks prior to his hospital admission, he developed Staphylococcus aureus and Pseudomonas aeruginosa infections that worsened his condition. After other treatments failed, the patient’s parents consented to a combination of ex vivo cell and gene therapy, in which cultures taken from a biopsy of uninvolved skin were used to develop transgenic epidermal grafts. The grafts were applied sequentially on a dermal wound bed.
“Virtually complete epidermal regeneration was observed after 1 month,” Dr. Hirsch and associates wrote. Over 21 months, the regenerated epidermis healed and remained stable even when subjected to mechanical stress.
For follow-up, the researchers reported on 10 punch biopsies taken at 4, 8, and 21 months after the grafting procedure. “The epidermis had normal morphology and we could not detect blisters, erosions, or epidermal detachment from the underlying dermis,” they noted.
The patient has remained stable since being discharged from the hospital in February 2016, and requires no ointment or medications to maintain a healthy epidermis, they said.
“This approach would be optimal for newly diagnosed patients early in their childhood,” Dr. Hirsch and associates noted. “A bank of transduced epidermal stem cells taken at birth could be used to treat skin lesions while they develop, thus preventing, rather than restoring, the devastating clinical manifestation that arise in these patients.
The study was supported in part by several government grants from organizations including the Italian Ministry of Education and the European Research. Two of the researchers are cofounders and members of the Board of Directors of Holostem Terapie Avanzate, which met all costs of good manufacturing practice production and procedures of transgenic epidermal grafts.
FROM NATURE