Treatment for central centrifugal cicatricial alopecia-Delphi consensus recommendations.

BACKGROUND: There is no established standard of care for treating central centrifugal cicatricial alopecia (CCCA), and treatment approaches vary widely. OBJECTIVE: To develop consensus statements regarding the use of various pharmacological therapies in treating adults with CCCA. METHODS: We invited 27 dermatologists with expertise in hair and scalp disorders to participate in a 3-round modified Delphi study between January and March 2023. Statements met strong consensus if 75% of respondents agreed or disagreed. Statements met moderate consensus if 55% or more but less than 75% agreed or disagreed. RESULTS: In round 1, 5 of 33 (15.2%) statements met strong consensus, followed by 9 of 28 (32.1%) in round 2. After the final round 3 meeting, strong consensus was reached for 20 of 70 (28.6%) overall statements. Two statements achieved moderate consensus. LIMITATIONS: This study included only English-speaking, US-based dermatologists and did not consider nonpharmacological therapies. CONCLUSION: Despite varying opinions among dermatologists, consensus was reached for several statements to help clinicians manage CCCA. We also highlight areas that lack expert consensus with the goal of advancing research and therapeutic options for CCCA.

A Novel Systems-Wide Approach in Addressing Acne with a Multi-Targeting Nutraceutical.

Acne vulgaris (AV) is one of the top concerns dermatologists encounter from women. Until now, therapies addressing AV have largely centered around, and have been successful at, targeting the pathophysiological mechanisms that occur at the pilosebaceous unit: sebum hypersecretion, follicular keratinization, over-proliferation of Cutibacterium acnes, and a localized immune response. In addition to these, there is good evidence to suggest that other systemic drivers of a generalized inflammatory response may contribute to the development or exacerbation of acne and that addressing these underlying factors may open more opportunities for developing effective treatments. These include psycho-emotional stress, diet and metabolism, hormonal fluctuations, skin and gut microbiome, oxidative stress, and immune response. While there is accumulating evidence that vitamins, minerals, and botanicals may mitigate some of the pro-inflammatory effects from the activation of these underlying systems, their use and recommendations are limited by a lack of quality efficacy and safety evidence. Here, we present the current evidence for the use of individual supplements in addressing the 6 systemic underlying drivers of AV. We also present a clinical study on the safety and efficacy of a nutraceutical combining many of these ingredients in the management of AV in men and women.  J Drugs Dermatol. 2024;23(3):160-167     doi:10.36849/JDD.8138.

Promoting a Healthy Skin Barrier Using Skin Care in People With Mature Skin Xerosis.

INTRODUCTION: Most people are living into their sixties and beyond. Fundamental changes in chronologically aged skin have significant and widespread dermatological implications. This review discusses aging-associated alterations in epidermal function leading to xerosis and related pruritus and the benefits of maintaining or restoring a healthy skin barrier using skincare, specifically ceramide-containing skincare.   Methods: A panel of 7 dermatologists convened for a meeting to review aspects of xerosis in mature skin, skin barrier changes, and nuances in the treatment and maintenance of mature skin using gentle cleansers and moisturizers. From the selected literature, 13 statements were drafted. During the meeting, the draft statements underwent the panel's evaluation at a workshop, followed by a plenary discussion adopting 5 statements using evidence from the literature coupled with the panel's opinions and experiences. RESULTS: The exact etiology of xerosis is not entirely understood and likely depends on several genetic and environmental mechanisms. Aging-associated changes in epidermal function include a marked reduction in total lipids in the stratum corneum relative to young skin due to reduced epidermal lipid synthesis. In aging skin, xerosis is significantly associated with pruritus. Studies have shown that lipid-containing skin care, such as a gentle ceramide-containing cleanser and moisturizer, promotes a healthy barrier reducing xerosis and pruritus in individuals with mature skin.  Conclusions: The development of xerosis in mature skin involves several genetic and environmental mechanisms. Skincare, including gentle cleansers and moisturizers, has reduced xerosis and pruritus in mature skin individuals.     J Drugs Dermatol. 2024;23(1):1253-1259.     doi:10.36849/JDD.7560.

Efficacy and Safety of DaxibotulinumtoxinA for Injection in the Treatment of Glabellar Lines by Age and Race: Subgroup Analysis of the SAKURA Clinical Trials.

BACKGROUND: DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin type A formulation approved for the treatment of glabellar lines. The efficacy, safety, and extended duration of response of DAXI 40 U for glabellar lines were demonstrated in 2 Phase 3, randomized, double-blind studies (SAKURA 1 and 2) and a Phase 3 open-label trial (SAKURA 3). OBJECTIVES: The aim of this study was to evaluate the efficacy and safety of the first DAXI 40 U treatment received in SAKURA 1, 2, or 3 across age and race subgroups. METHODS: Adults with moderate-to-severe glabellar lines (Investigator Global Assessment-Frown Wrinkle Severity [IGA-FWS] and Patient FWS [PFWS] scales) were evaluated for glabellar line severity for ≤36 weeks after the first DAXI treatment. Efficacy and safety were analyzed by age (18-45, >45-55, and >55 years) and race (Asian, Black and African American, and White). RESULTS: Overall, 2785 patients were included in the efficacy analysis. The proportion of patients achieving none or mild glabellar line severity at maximum frown (IGA-FWS) after DAXI treatment was high in all age and race subgroups (>96% at Week 4). Glabellar line severity of none or mild by composite IGA-FWS and PFWS rating was maintained for a median of 24.0 weeks in all age subgroups, and for 27.0, 25.3, and 24.0 weeks in the Asian, Black and African American, and White subgroups, respectively. Treatment-emergent adverse events were similar across all subgroups. CONCLUSIONS: Consistent with the overall study population, DAXI 40 U demonstrated a high response rate and duration of effect of ≥24 weeks across all age and race subgroups.

An update on cosmetic procedures in people of color. Part 2: Neuromodulators, soft tissue augmentation, chemexfoliating agents, and laser hair reduction.

Recent years have brought forth the undeniable practice gap in dermatology concerning knowledge and experience of cosmetic procedures in people of color (POC). A paucity in the literature regarding evidence-based recommendations for the management of POC undergoing cosmetic procedures and the rise of cosmetic procedures in dermatology serves as a call to action to provide education regarding differences in skin of color that may impact the cosmetic outcomes. To mitigate the current practice gap on the safety, use, and benefits of cosmetic procedures in POC, part 2 will discuss the authors' recommendations and clinical pearls, as well as evidence-based management for neuromodulators, soft tissue augmentation, chemexfoliating agents, and laser hair reduction in POC undergoing cosmetic procedures.

An update on cosmetic procedures in people of color. Part 1: Scientific background, assessment, preprocedure preparation.

Increased life expectancy, focus on appearance, and readily available and accessible cosmetic procedures have served to drive an increase in the number of nonsurgical cosmetic procedures performed in the last 20 years. Demographic shifts in the United States, with increases in diverse populations that seek nonsurgical cosmetic procedures, have resulted in the need for a better understanding of cultural preferences as well as structural and biological differences in the skin of people of color (POC). Although many advances in the form of cosmeceuticals, cosmetics, and photoprotection have been made to address the aesthetic needs of and minimize complications in POC, nonsurgical cosmetic procedures are required to address common aesthetic concerns. Gaps remain in the education of dermatologists regarding the appropriate selection and execution of nonsurgical cosmetic procedures in POC. This educational initiative will facilitate a favorable outcome and optimal cosmetic results for POC.

Global Perspectives of the Patient of Color

Many cultures associate beauty with an even complexion. It has been shown in many reported references, the major cosmetic concern in patients of color is discoloration. This issue addresses discoloration of individuals of color and the use of a multitude of preparations that can blend the complexion. Authors in Asia, Sweden, France, and Brazil discuss the use of injectable deoxycholic acid in nonsubmental regions and hyaluronic acid for skin boosting, an off-label usage or procedures in the United States. Skin boosting improves hydration and the smoothness of the skin. Additionally, international methods of treating cosmetic patients with multiple modalities are discussed.

Laser Treatment of Skin of Color for Medical and Aesthetic Uses With a New 650-Microsecond Nd:YAG 1064nm Laser

Individuals with skin of color are a rapidly growing portion of the cosmetic procedures market. There are unique challenges to treating skin conditions in skin of color patients. This article and roundtable discussion focus on the use of energy-based modalities, particularly a 650-microsecond 1064nm laser that delivers energy in a collimated beam. Alone or in combination with other therapies, the 650-microsecond 1064nm laser has been used successfully to treat melasma, acne, postinflammatory hyperpigmentation, pseudofolliculitis barbae, hair removal, acne keloidalis nuchae, and aging skin in skin of color. J Drugs Dermatol. 2019;18(4 Suppl 1):s135-137.

Practical Applications for Medical and Aesthetic Treatment of Skin of Color With a New 650-Microsecond Laser

The following roundtable is edited from discussion between the authors concerning treatment with the 650-microsecond 1064nm Nd:YAG laser. These dermatologist experts share their expertise, experience, and treatment pearls regarding the device for medical and aesthetic use, and in treatment of skin of color (SOC).

Three-Dimensional Analysis of Minimally Invasive Vacuum-Assisted Subcision Treatment of Cellulite.

INTRODUCTION: This was a prospective non-randomized observational study of female subjects seeking treatment for cellulite who were consecutively enrolled into a registry. The objective was to evaluate the efficacy and safety of a tissue stabilized-guided subcision device for the treatment of cellulite using three-dimensional (3D) imaging analysis. METHODS: Subjects received a single treatment to the buttocks and/or posterolateral thighs with the study device. Follow-up telephone evaluations were conducted at 3 and 14 days to evaluate safety and 30 and 90 days to evaluate efficacy. Subjects returned to clinic at three months to obtain follow-up two dimensional and 3D imaging. RESULTS: Sixteen women of average age 44.1 years with a total of 291 lesions of cellulite were treated. Thirteen subjects presented for all follow up visits. Physicians graded results an average of 2.23/5 or "much improved" to "improved" with 9 subjects as much or very much improved (69.2%). Blinded assessors graded overall improvement an average of 2.8 (26-75% improvement) with 8 subjects having greater than 50% improvement overall (61.6%). Improvement in dimple depth was graded an average of 2.9, with 9 subjects having greater than 50% improvement (69.2%). Analysis of 3D imaging yielded 67.4% average improvement in negative volume and 58.4% improvement in minimum height of dimples. Most expected treatment effects resolved within three months after treatment. CONCLUSION: Utilizing three-dimensional imaging analysis, investigators quantitatively and objectively demonstrated efficacy of a tissue stabilized-guided subcision device in the treatment of cellulite of the buttocks and thighs. J Drugs Dermatol. 2018;17(9):960-965.

Assessing the Potential Role for Topical Melatonin in an Antiaging Skin Regimen.

BACKGROUND: Melatonin is an endogenous hormone commonly associated with regulation of sleep. However, over the last two decades, research has elucidated a range of effects associated with the compound, including anti-inflammatory, both direct and indirect antioxidant activity, tissue regenerative benefits, and preservation of mitochondrial function. Melatonin's anti-inflammatory and antioxidant support, coupled with its mitochondrial support, make it an intriguing target for use to support skin health. Human skin and hair follicles express functional melatonin receptors. They also engage in substantial melatonin synthesis. By supporting cutaneous homeostasis, melatonin and its metabolites are thought to attenuate carcinogenesis and possibly other pathological processes, including hyperproliferative/inflammatory conditions. The primary extrinsic driver of aging has been considered to be exposure to ultraviolet (UV) light, which is well-established to contribute to sunburn, immunosuppression, skin aging, and carcinogenesis. Topically applied melatonin has been shown to reduce markers of reactive oxygen species formation and to reverse signs of skin aging. As the global population continues to age, photo-damage remains a significant cutaneous concern. While use of sunscreens and UV avoidance strategies are essential to mitigate skin cancer risks, the potential to protect the skin and improve the appearance of photo-damage through the use of topical antioxidant support is appealing. The evidence suggests that melatonin deserves consideration for topical use as an anti-aging and skin protective agent. It is shown to be both safe and effective when topically applied. J Drugs Dermatol. 2018;17(8):966-969.

Considerations When Treating Cosmetic Concerns in Men of Color.

BACKGROUND: Men of color include a diverse population encompassing individuals with Fitzpatrick skin Types IV through VI. Yet, there is a paucity of data describing the cosmetic concerns of this population. OBJECTIVE: To review the basic science of advantages and disadvantages of skin of color and pathophysiology, incidence, and treatment of disorders of cosmetic concern in men of color. METHODS: A MEDLINE search was performed for publications on sex and racial differences in basic science of skin, common disorders in men of color, and evidence-based treatments. RESULTS: There are intrinsic differences in skin and hair of darker-complexioned men, particularly in Hispanics, African Americans, Asians, and Afro-Caribbeans. Advantages of darker skin include increased photoprotection, slowed aging, and a lower incidence of skin cancer. However, the increased content of melanin is associated with myriad dyschromias including melasma and postinflammatory hyperpigmentation (PIH). Additional common skin conditions of concern in men of color include pseudofolliculitis barbae, acne keloidalis nuchae, and keloids. CONCLUSION: A skin color conscious approach should be administered in caring for the cosmetic concerns of men of color that is cognizant of differences in biology of the skin and hair, associated PIH of disorders, and cultural/social practices among this population.

Delivery of alcohol brief interventions in community-based youth work settings: exploring feasibility and acceptability in a qualitative study.

BACKGROUND: Alcohol Brief Interventions (ABIs) are increasingly being delivered in community-based youth work settings. However, little attention has been paid to how they are being implemented in such settings, or to their feasibility and acceptability for practitioners or young people. The aim of this qualitative study was to explore the context, feasibility and acceptability of ABI delivery in youth work projects across Scotland. METHODS: Individual, paired and group interviews were conducted with practitioners and young people in nine community projects that were either involved in the delivery of ABIs or were considering doing so in the near future. A thematic analysis approach was used to analyse data. RESULTS: ABIs were delivered in a diverse range of youth work settings including the side of football pitches, on the streets as part of outreach activities, and in sexual health drop-in centres for young people. ABI delivery differed in a number of important ways from delivery in other health settings such as primary care, particularly in being largely opportunistic and flexible in nature. ABIs were adapted by staff in line with the ethos of their project and their own roles, and to avoid jeopardising their relationships with young people. Young people reacted positively to the idea of having conversations about alcohol with youth project workers, but confirmed practitioners' views about the importance of these conversations taking place in the context of an existing trusting relationship. CONCLUSION: ABIs were feasible in a range of youth work settings with some adaptation. Acceptability to staff was strongly influenced by perceived benefits, and the extent to which ABIs fitted with their project's ethos. Young people were largely comfortable with such conversations. Future implementation efforts should be based on detailed consideration of current practice and contexts. Flexible models of delivery, where professional judgement can be exercised over defined but adaptable content, may be better appreciated by staff and encourage further development of ABI activity.

Parents' perspectives of a universal early attachment programme in Scotland.

The 'A Good Start' programme is a universal early attachment programme for parents and babies aged 8 weeks and over, run by a charitable organization in one Scottish local authority. The programme offers non-stigmatizing support and parents are encouraged to access other community resources on completing it. At a family level, the programme aims are that parents (i) have an increased feeling of well-being; (ii) are more attuned to their babies and (iii) are more aware of services and confident in becoming involved with them. The collaborative research study was undertaken by a small research team between March 2014 and January 2015. It had two strands-a collaborative element which involved developing and supporting the use of the outcomes frameworks together with project staff and direct evaluation work, namely collation of the 'A Good Start Web' outcome measurement tool results and conducting interviews and focus groups with parents, staff and volunteer instructors who delivered the programme. The objectives of the evaluation were to evaluate the extent to which the programme were met, using the 'A Good Start Web' outcome measurement tool, augmented by qualitative data. It was clear from the qualitative evaluation data that most parents who participated in the programme felt that they benefited from it in many ways. Parents valued the opportunity to meet with other parents for peer support, to undertake a practical activity to enhance the bond with their baby which relaxed them both and to reduce their anxiety about caring for an infant.

Consensus Recommendations for Combined Aesthetic Interventions Using Botulinum Toxin, Fillers, and Microfocused Ultrasound in the Neck, Décolletage, Hands, and Other Areas of the Body.

BACKGROUND: The popularity of aesthetic procedures in the face has led to greater disparity between treated areas and those that still show evidence of true age. Although many areas of the body often require multiple treatment procedures for optimal rejuvenation, combination therapy for specific areas is not yet well defined. OBJECTIVE: To develop recommendations for the optimal combination and ideal sequence of botulinum toxin (BoNT), hyaluronic acid, calcium hydroxylapatite (CaHA), and microfocused ultrasound with visualization in nonfacial areas across all skin phototypes. METHODS: Fifteen specialists convened under the guidance of a certified moderator. Consensus was defined as approval from 75% to 94% of all participants, whereas agreement of ≥95% denoted a strong consensus. RESULTS: Recommendations have been provided for the neck, décolletage, and hands and include the timing and sequence of specific procedures when used concurrently or over several treatment sessions. Position statements are offered in lieu of consensus for the upper arms, abdomen, buttocks, and knees. CONCLUSION: Nonfacial rejuvenation often requires multiple procedures for optimal results in individuals with significant age-related changes. Further clinical studies are recommended to raise awareness of non-facial indications and provide clinicians with the best evidence for best treatment practices.

Consensus Recommendations for Combined Aesthetic Interventions in the Face Using Botulinum Toxin, Fillers, and Energy-Based Devices.

BACKGROUND: The aging process is a complex interplay of intrinsic and extrinsic factors across multiple layers of the face. Accordingly, combining aesthetic interventions targeting different manifestations of aging often leads to better results than single modalities alone. However, no guidelines for a pan-facial approach using multiple interventions have been published to date. OBJECTIVE: To develop consensus recommendations for the optimal combination and ideal sequence of botulinum toxin (BoNT), hyaluronic acid, calcium hydroxylapatite, and microfocused ultrasound with visualization (MFU-V) in persons of all Fitzpatrick skin types. METHODS AND MATERIALS: Fifteen specialists convened under the guidance of a certified moderator. Consensus was defined as approval from 75% to 94% of all participants, whereas agreement of ≥95% denoted a strong consensus. RESULTS: Optimal aesthetic treatment of the face begins with a thorough patient assessment and an individualized treatment plan. Spacing consecutive treatments 1 to 2 weeks apart allows for resolution of side effects and/or to assess results. For same-day treatments, BoNT and fillers may be performed together in either sequence, whereas MFU-V is recommended before injectable agents. CONCLUSION: Expert consensus supports a combination approach using multiple modalities in specific sequence for the safe and effective treatment of the aging face.

The Efficacy and Safety of Topical Dapsone Gel, 5% for the Treatment of Acne Vulgaris in Adult Females With Skin of Color.

BACKGROUND: Topical dapsone gel, 5% is approved for treatment of acne vulgaris but has not been studied specifically in women with skin of color (SOC; Fitzpatrick skin types IV, V, or VI). OBJECTIVE: Evaluate safety and efficacy of dapsone gel, 5% applied topically twice daily for 12 weeks in women with SOC. METHODS: Females with SOC aged 18 years and older with facial acne participated in a multicenter, open-label, single-group, 12-week pilot study of twice-daily monotherapy with dapsone gel, 5%. The investigator-rated 5-point Global Acne Assessment Score (GAAS) was used to assess efficacy. The impact of acne on subjects was assessed using the validated Acne Symptom and Impact Scale (ASIS). RESULTS: The study enrolled and treated 68 women with SOC and facial acne. GAAS decreased significantly from baseline to week 12 (mean, -1.2 [95% CI, -1.4, -1.0]; P<.001), a 39.0% improvement. Overall, 42.9% of subjects were responders based on a GAAS of 0 or 1 at week 12. Subjects also experienced significant reductions in mean total lesions (52% decrease), inflammatory lesions (65%), and comedo counts (41%; all P<.001). Dapsone gel, 5% monotherapy was associated with significant improvement in subject-assessed acne signs (P<.001) and impact on quality of life (QOL; P<.001), based on ASIS. Dapsone gel, 5% used twice daily was well tolerated, with no treatment-related adverse events. The local dermal tolerability scores tended to remain stable or decrease from baseline to week 12. CONCLUSIONS: Monotherapy with dapsone gel, 5% administered twice daily was safe and effective for treatment of facial acne in women with SOC. Significant improvement in overall acne severity and both inflammatory lesions and comedones was observed. Further, study subjects reported considerable improvement in both acne signs and impact on QOL.

A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown Lines.

BACKGROUND: IncobotulinumtoxinA and onabotulinumtoxinA are indicated for the temporary improvement in the appearance of glabellar frown lines (GFL). This is the first randomized direct comparator study to date, at the Food and Drug Administration-recommended dose of 20 units (U), for the treatment of GFL. OBJECTIVE: To investigate the dose equivalence of incobotulinumtoxinA (20 U) and onabotulinumtoxinA (20 U) for the treatment of moderate-to-severe GFL. MATERIALS AND METHODS: Prospective, randomized (1:1), double-blinded, parallel-group study in 250 females (18-50 years), employing a single treatment with incobotulinumtoxinA or onabotulinumtoxinA, followed by a 4-month observational period. RESULTS: At the primary efficacy endpoint (1 month after treatment), incobotulinumtoxinA was equivalent to onabotulinumtoxinA in the treatment of GFL at the 20 U dose within the prespecified ± 15% margin of equivalence. Efficacy remained similar between treatment groups through 4 months after treatment as assessed by the independent masked panel and the masked treating physicians. Patient satisfaction ratings were similar between groups and favorable (>90%) throughout. Both treatments were well tolerated. CONCLUSION: Equivalence was demonstrated at the primary endpoint between incobotulinumtoxinA and onabotulinumtoxinA in the treatment of GFL at the 20 U dose at 1 month. Similar efficacy and tolerability profiles were observed through 4 months after treatment.