Medical and procedural treatment of androgenetic alopecia - Where are we?

Novel medical and procedural options for androgenetic alopecia have arrived. Low-dose oral minoxidil has made its clinical debut, while data on spironolactone, finasteride, and nutritional supplements have advanced. Minimally invasive technological advancements include photobiomodulation and platelet-rich plasma. Within hair transplantation, follicular unit extraction and robotics are now at the clinicians' fingertips.

Combination therapy in female pattern hair loss.

Patterned hair loss is a common type of non-scarring alopecia, characterized by miniaturization of hair follicles. The etiology of female pattern hair loss (FPHL) is not clearly linked to androgens or other hormones thereby making it a challenging condition to treat. Various treatment modalities, like minoxidil (topical or oral), spironolactone, finasteride, have been tried alone or in combination with variable results. Combination therapy is superior to the monotherapy, since these multiple treatment modalities act by targeting different pathogenetic pathways, making the treatment aggressive and more effective.

Real-World, Open-Label Study of the Efficacy and Safety of a Novel Serum in Androgenetic Alopecia.

Pattern-type hair loss is a highly prevalent condition affecting the majority of men and women at some point in their lifetime. Although genetics and androgens are instrumental in the pathogenesis of this type of hair loss, it is increasingly recognized that inflammation, stress, and environmental factors play a central role. The few and widely used monotherapies approved by the US Food and Drug Administration, such as minoxidil or finasteride, are not efficacious in all people and cause adverse events that prevent patient compliance. Therefore, new treatments that are easy to use and that holistically address the multi-factorial pathophysiology of pattern-type hair loss are needed. Clinical studies have already demonstrated the safety and efficacy of a plethora of bioactive natural products, such as epigallocatechin gallate (EGCG), Vitis vinifera seed extract, Glycyrrhiza root extract, apigenin, and saw palmetto extract to name a few, in improving hair follicle homeostasis via anti-inflammatory, anti-androgen, anti-microbial, and anti-oxidant action. Here, we present a novel topical serum, REVIVV®, that contains a proprietary blend of phytochemicals designed to stimulate hair growth, reduce shedding, and restore homeostasis to the hair follicle. The serum’s safety and efficacy were assessed in 150 participants in a real-world clinical setting. Findings demonstrate that twice-daily use of the serum significantly improves hair growth, and reduces shedding after 8 weeks of use. All participants rated the serum as easy to use and stated plans for continued use. Overall, the topical serum REVIVV® showed evidence of good efficacy related to hair growth and had positive cosmetic properties warranting further evaluation in clinical studies. Rapaport J, Sadgrove NJ, Arruda S, et al. Real-world, open-label study of the efficacy and safety of a novel serum in androgenetic alopecia. J Drugs Dermatol. 2023;22(6):559-564. doi:10.36849/JDD.7403.

Carboxytherapy Mask as Post Nanofractional Radiofrequency Treatment for Improvement of Facial Skin Quality and Photoaging.

BACKGROUND: Skin rejuvenation can be achieved with minimally invasive treatments using energy-based devices that feature reduced side effects and downtime. Post-treatment care is key to minimize any potential side effects and skin reactions such as erythema, dryness, or dyschromia. OBJECTIVE: The objective of this study was to evaluate the efficacy and patient satisfaction of a novel carboxytherapy gel mask compared with petroleum-based lanolin-containing ointment to accelerate wound healing facial post-nanofractional radiofrequency treatment. METHODS AND MATERIALS: Ten subjects were enrolled in this pilot, prospective, randomized, single-blind study and randomized into two arms. One arm received one nanofractional radiofrequency treatment with ointment right after and four consecutive days of ointment applications twice a day, while the second arm followed this regimen with a carboxytherapy gel mask application right after and four consecutive days after treatment. Investigator, safety, and patient assessments were conducted at 24 hours and one-week post treatment. Safety was monitored throughout. The primary endpoint was defined as the degree of investigator global assessment (IGA) in photodamage, pigmentation, and wrinkles using standardized photographs. Secondary endpoints included investigator-rated degree of erythema, edema, crusting, exudation, percentage healing, improvement of skin quality, and patient satisfaction. RESULTS: Nine patients completed the study. There was improvement of one degree in IGA for photodamage, pigmentation and wrinkles in all patients using the carboxytherapy gel mask at the one-week follow up. Blinded investigator ratings showed significant improvement of dryness, erythema, edema, crusting, and percentage healing at the 24-hour follow up, with all patients remaining the same a week post treatment. All patients in the carboxytherapy group were satisfied with the treatment and had no adverse effects. Three patients in the petroleum-based lanolin-containing group experienced mild edema and acne breakout that resolved two weeks after treatment. CONCLUSION: Carboxytherapy delivered via a gel mask after skin rejuvenation procedures is a safe and effective strategy to improve clinical outcomes and reduce post-treatment side effects. J Drugs Dermatol. 20(4):461-465. doi:10.36849/JDD.5856.

Laser treatment for facial acne scars: A review.

BACKGROUND AND OBJECTIVES: Acne scarring is a widely prevalent condition that can have a negative impact on a patient's quality of life and is often worsened by aging. A number of options are available for the treatment of acne scarring, including retinoids, microdermabrasion, dermal fillers, and surgical techniques such as subcision. The aim of this review is to evaluate the different laser modalities that have been used in peer-reviewed clinical studies for treatment of atrophic acne scars, and summarize current clinical approaches. MATERIALS AND METHODS: A Medline search spanning from 1990 to 2016 was performed on acne scarring. Search terms included "atrophic acne scars," "ablative'', "nonablative," "fractional," "nonfractional," "neodymium," "alexandrite," "pulsed dye" lasers, and results are summarized. RESULTS: Various types of lasers have been evaluated for the treatment of atrophic acne scars. While they are efficacious overall, they differ in terms of side effects and clinical outcomes, depending on patients skin and acne scar type. A new emerging trend is to combine lasers with other energy-based devices and/or topicals. CONCLUSION: Evaluation of the literature examining acne scar treatment with lasers, revealed that clinical outcomes are dependent on various patient factors, including atrophic acne scar subtype, patient skin type, treatment modality, and side-effect profile.

A randomized, single-blind, study evaluating a 755-nm picosecond pulsed Alexandrite laser vs. a non-ablative 1927-nm fractionated thulium laser for the treatment of facial photopigmentation and aging.

Background: Laser toning is one of the most popular strategies to treat facial photopigmentation and aging. Several laser modalities, including fractional non-ablative, Q-switched (QS) lasers and new generation picosecond lasers have been used for this indication. However, there is paucity of head to head comparisons of older generation of lasers with new ones. Objective: To compare a 755 nm picosecond pulsed alexandrite laser with a non-ablative 1927 nm fractionated thulium laser for the treatment of facial photopigmentation and aging through a randomized, single-blind study. Materials and methods: 20 subjects (skin types I-IV) were randomized to receive either four 755-nm picosecond alexandrite laser treatments, spaced 3 weeks apart, or two dual wavelength thulium fiber fractionated 1550/1927 nm laser treatments, spaced 6 weeks apart. Follow-up assessment visits occurred 4 and 12 weeks after the last study treatment. Results: At the 4- and 12-week follow-up, both groups showed significant improvement of photoaging, pigmentation, skin quality according to the investigator and subjects assessments. When comparing the two groups, subjects in 755 nm group had statistically significant greater improvement in investigator assessments of photoaging/skin quality and subject satisfaction than those in the 1927 nm group. Conclusion: Both the non-ablative 1927 and 755 nm picosecond laser can improve facial photopigmentation, but the latter can yield superior results with less pain and side effects according to patient and investigator assessments.

A prospective, randomized, double-blinded, split-face pilot study comparing Q-switched 1064-nm Nd:YAG versus 532-nm Nd:YAG laser for the treatment of solar lentigines.

Treating photoaging with laser technologies has increased in popularity due to their efficacy, minimal downtime, and side effects. New Q-Switched (QS) Nd:YAG lasers' frequency doubled with 532 nm wavelength can both target epidermal chromophores as well as stimulate collagen production. The objective of this study was to compare single-pulsed 1064-nm Nd:YAG with dual-pulsed 532-nm/1064-nm QS laser for reducing solar lentigines. Ten subjects with solar lentigines were enrolled in this prospective, randomized, double-blind, split-face study. Subjects received six laser treatments (half-face dual, half single) at 2-week intervals. Blinded investigator and subject assessments were conducted 1 month posttreatment to evaluate global skin improvement, safety, and patient satisfaction. Blinded investigator assessments showed statistically significant improvement in the dual-treated side. Patient satisfaction was also statistically significantly increased in the dual-treated side. In conclusion, dual laser treatment can result in superior and safe global improvement of photoaging.

Photobiomodulation therapy for androgenetic alopecia: A clinician's guide to home-use devices cleared by the Federal Drug Administration.

The market for home-use photobiomodulation devices to treat androgenetic alopecia has rapidly expanded, and the Food and Drug Administration (FDA) has recently cleared many devices for this purpose. Patients increasingly seek the advice of dermatologists regarding the safety and efficacy of these hair loss treatments. The purpose of this guide was threefold: (1) to identify all home-use photobiomodulation therapy devices with FDA-clearance for treatment of androgenetic alopecia; (2) to review device design, features and existing clinical evidence; and (3) to discuss practical considerations of photobiomodulation therapy, including patient suitability, treatment goals, safety, and device selection. A search of the FDA 510(k) Premarket Notification database was conducted using product code "OAP" to identify all home-use devices that are FDA-cleared to treat androgenetic alopecia. Thirteen commercially available devices were identified and compared. Devices varied in shape, wavelength, light sources, technical features, price, and level of clinical evidence. To date, there are no head-to-head studies comparing the efficacy of these devices. Photobiomodulation therapy devices have an excellent safety profile and mounting evidence supporting their efficacy. However, long-term, high quality studies comparing these devices in diverse populations are lacking. As these devices become increasingly popular, dermatologists should be familiar with this treatment modality to add to their therapeutic armamentarium. ABBREVIATIONS: AGA, androgenetic alopecia; FDA, Food and Drug Administration; IEC, International Electrotechnical Commission; LED, light-emitting diode; PBMT, photobiomodulation therapy.

New-Generation Therapies for the Treatment of Hair Loss in Men.

Hair loss affects millions of people worldwide and can have devastating effects on an individual's psychoemotional well-being. Today hair restoration technologies through hair transplantation have advanced with the use of robots and follicular unit extraction/grafting that can offer patients excellent clinical results. Adjuvant modalities, such as platelet-rich plasma injections, lasers, and stem cells, can further enhance durability, health, and appearance of hair transplants.

Efficacy of multipolar radiofrequency with pulsed magnetic field therapy for the treatment of abdominal cellulite.

INTRODUCTION: Cellulite is a metabolic condition, predominately seen in females, that affects the subcutaneous tissue of the posterolateral thighs, buttocks, pelvic region, and abdomen. It is characterized by skin dimpling and lumpiness resembling an orange peel. Despite the wide range of treatment options for patients with cellulite, there is a paucity of empirical data supporting their efficacy. The objective of this study was to evaluate the efficacy of a new-generation multipolar radiofrequency (RF) device for the treatment of cellulite. METHODS: A multipolar RF device with pulsed magnetic fields was used to treat abdominal cellulite. Twenty-five healthy adult females with stage II or stage III abdominal cellulite underwent 8 weekly treatments. Assessments were performed at baseline and at weeks 1, 4, and 12 following the final treatment. RESULTS: Reduction in subcutaneous thickness in the axial and sagittal plane of the abdomen was observed at 1 week following treatment initiation. Results from self-reported questionnaires revealed a significantly high level of patient satisfaction (60%). Assessments by a blinded investigator at one, four, and twelve weeks after the final treatment demonstrated a significant improvement in cellulite appearance. No adverse effects were reported and the treatment was well tolerated. CONCLUSION: This study demonstrates the safety, efficacy, and subject satisfaction of multipolar RF with pulsed magnetic field therapy in the treatment of abdominal cellulite.

Hand Rejuvenation Using a Combination Approach.

BACKGROUND: Hand rejuvenation has been recognized to play a key role in complementing and restoring an overall youthful look. OBJECTIVE: Aging hands present specific characteristics that require a carefully designed combinational treatment for a successful clinical outcome from a practitioner's and patient's perspective. METHODS AND MATERIALS: A Medline search was performed on hand rejuvenation from 1990 to 2015, and results are summarized. The authors' personal experiences with specific technologies are discussed. RESULTS: Review of available clinical studies revealed successful rejuvenation of the epidermis and dermis of the hands with topicals, chemical peels, intense pulsed light, and laser energy devices. Reports of sclerotherapy and laser veins ablation for dorsal hand veins were identified. Several studies on hand volume restoration with injectable volumetric fillers such as hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, autologous fat transfer including the authors' personal experience with them are described. CONCLUSION: A plethora of noninvasive treatment options for hand rejuvenation have been thoroughly studied as monotherapy, but there is insufficient number of studies evaluating the best combination of therapies for this indication. It is likely that their strategic combination and sequence of application by a trained clinician will ensure a favorable outcome in addressing patient concerns.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations.

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

A novel approach to structural facial volume replacement.

UNLABELLED: Improved understanding of the anatomy and physiology of the aging face has laid the foundation for adopting an earlier and more comprehensive approach to facial rejuvenation, shifting the focus from individual wrinkle treatment and lift procedures to a holistic paradigm that considers the entire face and its structural framework. This article presents an overview of a comprehensive method to address facial aging. The key components to the reported strategy for improving facial cosmesis include, in addition to augmentation of volume loss, protection with sunscreens and antioxidants; promotion of epidermal cell turnover with techniques such as superficial chemical peels; microlaser peels and microdermabrasion; collagen stimulation and remodeling via light, ultrasound, or radiofrequency (RF)-based methods; and muscle control with botulinum toxin. For the treatment of wrinkles and for the augmentation of pan-facial dermal lipoatrophy, several types of fillers and volumizers including hyaluronic acid (HA), autologous fat, and calcium hydroxylapatite (CaHA) or injectable poly-L-lactic acid (PLLA) are available. A novel bimodal, trivector technique to restore structural facial volume loss that combines supraperiosteal depot injections of volume-depleted fat pads and dermal/subcutaneous injections for panfacial lipoatrophy with PLLA is presented. The combination of treatments with fillers; toxins; light-, sound-, and RF-based technologies; and surgical procedures may help to forestall the facial aging process and provide more natural results than are possible with any of these techniques alone. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of a neuromuscular electrical stimulation device for facial muscle toning: a randomized, controlled trial.

BACKGROUND: Age-related loss of muscle mass contributes to aging of the human face. AIMS: To evaluate the effects of a neuromuscular electrical stimulation (NMES) device on facial muscle tone and signs of facial aging in healthy women. PATIENTS/METHODS: One hundred and eight healthy women (mean age 43.7, range 32 to 58-45 years) participated in this randomized, controlled, partially blinded study. Participants were randomized to 12 weeks' treatment with the NMES facial device (20 min/day, 5 days/week) or to a nonintervention control group. Participants could not alter fitness, diet or facial care routines during the study. Assessments included psychometric evaluations of facial appearance and assessor-blinded ultrasound measurements of the thickness of the zygomatic major muscle. RESULTS: Mean muscle thickness increased vs. baseline in the NMES group (18.6%) but not the control group. Between-group differences were significant at 6 and 12 weeks (P = 0.05 and P = 0.0001). NMES users reported subjective improvements in facial attributes. The control group did not. In an overall evaluation, ≥80% of NMES users reported improved firmness, tone and lift vs. <5% of the control group (P < 0.001). CONCLUSIONS: A 12-week course of facial NMES was associated with increased thickness of the zygomatic major muscle and subjective improvements in facial attributes.

Treatment of mild-to-moderate acne vulgaris using a combined light and heat energy device: home-use clinical study.

INTRODUCTION: Light and heat devices have become widely used for the treatment of mild-to-moderate inflammatory acne as an alternative to retinoids and antibiotics. The purpose of this study was to examine whether a hand-held device that emits both light and heat energy can safely and effectively be applied at home to shorten the time to improvement and time to resolution of acne papules and pustules. METHODS: A two-center, randomized, placebo-controlled, double-blind study was conducted on 63 subjects with at least four inflamed, facial, acne lesions. Treatments were self-administered twice a day for 4 days. All lesions were photographed on a daily basis. Treatment results were assessed by two blinded evaluators, based on the macro photographs, using a 4-point visual analogue scale (VAS) and a photographic lesion reference scale (PLRS), as well as by the subjects. Safety was assessed based on evaluators and subjects' reported side effects and adverse events. RESULTS: Twenty-nine subjects in the treatment arm and 32 subjects in the placebo arm, with skin types II-VI, successfully completed the study. Based on blinded VAS scores, 92.24% of the lesions treated with an active device improved within a median time of 1 day versus 75.78% and a median time of 2 days for the placebo arm. At 24 hours the improvement rate was 76.72% for the active arm versus 15.63% for the placebo arm. Based on blinded PLRS scores, 87.07% of the lesions treated with an active device improved within a median time of 2 days versus 64.8% and 3 days for the placebo. A total of 51.7% of the active arm lesions resolved within a median time of 4 days versus 36% (no median) for the placebo arm lesions. No device-related adverse events occurred throughout the study. CONCLUSION: This study demonstrates the safety and effectiveness of the hand-held, combined light and heat energy device for at-home treatment of individual mild-to-moderate inflammatory acne lesions. Statistically significant shorter lesion improvement and lesion resolution rates were found.

New clinical outcomes utilizing a 1064-nm Nd:YAG laser for lipolysis of the torso oblique region.

OBJECTIVES: The safety and efficacy of a 1064-nm Nd:YAG laser (Cynosure, Westford, USA) utilizing a 300-microm optical fiber and a 1-mm diameter micro-cannula were evaluated as a treatment for reduction in the appearance or elimination of unwanted fat in the lower back/flanks ('love handles'). In addition, the use of the laser for tightening the skin and collagen regeneration in the area of lipolysis was assessed through biopsies. METHODS: Ten subjects with unwanted flaccidity and fat deposits in the oblique region of the torso were enrolled in the study. Subjects underwent a single laser lipolysis treatment followed by aspiration of the treatment area. The total tumescence used, laser energy delivered, and tissue removed was recorded for each subject. All subjects had baseline photographs taken and their weight recorded prior to treatment. Pregnancy tests (if applicable) were performed prior to treatment as well. Three subjects had 4-mm biopsies taken at baseline and 6 months to evaluate collagen regeneration. Collagen and elastic tissue fibers were evaluated using special routine stains and histochemical stains designed to highlight these dermal components. Follow-up visits were conducted at 1 week, 1 month, 3 months and 6 months following treatment to evaluate side effects, weight loss and laxity. Additionally, patients kept an evaluation log for each of the first 7 days following treatment. At the 6-month conclusion, patient satisfaction was recorded. RESULTS: Laser lipolysis procedures with subsequent aspiration were performed bilaterally on the flanks of 10 subjects. At 1-week post-treatment, 80% of the subjects demonstrated reduction in laxity. Similarly, 100% of patients showed visible skin improvement at 1 month, with 70% recording a score of 2 (good improvement). Three-month evaluations yielded one patient (10%) with a score of 3 (excellent improvement) and seven patients (70%) with a score of 2. Histology reports confirmed the visual clinical outcomes, describing thicker collagen bundles at 6 months, as well as coagulation of blood vessels and adipocytes. Side effects were mild and transient in nature, and the majority of discomfort, redness, bruising, swelling, and tingling experienced was resolved within 1 week post-procedure. The treatment was well tolerated and efficacious, with 90% of patients rating their results as good or excellent and 100% of patients reporting that they would recommend the procedure. CONCLUSION: The use of the 1064-nm Nd:YAG laser with a 300-microm fiber demonstrated the ability to treat adipose tissue in the highly vascular flank area with favorable efficacy and safety. Patients exhibited a quick recovery time and excellent tolerance, as well as visually improved skin.

An open-label, split-face study comparing the safety and efficacy of levulan kerastick (aminolevulonic acid) plus a 532 nm KTP laser to a 532 nm KTP laser alone for the treatment of moderate facial acne.

Recent advances in light therapy coupled with photosensitizers offer alternatives to topical creams and gels and systemic oral agents for acne treatment. To examine the safety and efficacy of the photosensitizer 5-aminolevulinic acid (ALA) in patients with moderate-to-severe acne, a randomized, split-face study, using ALA on one side of the face, was followed by exposure of the entire face to 532 nm potassium titanyl phosphate (KTP) laser. Eight patients completed three treatments for up to 12 weeks. The average acne grading at baseline was 3.20, and improved to 2.12 at 12 weeks (34% improvement). Use of ALA improved acne by 52% compared with 32% on the side that did not receive the photosensitizer. Further studies are warranted to establish optimal parameters for photosensitizer use combined with light therapy for treatment of moderate-to-severe acne; however, the combined use of ALA and a 532 nm laser suggests promising results for acne treatment.

Treatment of cellulite: Part II. Advances and controversies.

Treatments for localized adiposities range from topical creams to liposuction. Most treatments lack a substantial proof of efficacy. The unpredictable treatment outcome can be related to the fact that cellulite adipose tissue is physiologically and biochemically different from subcutaneous tissue found elsewhere in the body. Part II of this two-part series on cellulite reviews the various treatment options that are currently available for human adipose tissue including, but not limited to, cellulite. It also focuses on newer techniques that can be potentially useful in the future for the treatment of cellulite.

A study to determine the effect of combination blue (415 nm) and near-infrared (830 nm) light-emitting diode (LED) therapy for moderate acne vulgaris.

BACKGROUND AND OBJECTIVE: Acne vulgaris remains a major problem in dermatological practice. Phototherapy for acne with blue (415 nm) and red (633 nm) light-emitting diode (LED) arrays has recently attracted attention. This pilot study assessed the efficacy of the combination of 415 nm and near-infrared (IR) LED therapy for moderate acne. METHODS: Seventeen individuals were recruited: 13 females and four males. Skin types ranged from type II to type VI, and the acne grades at baseline ranged from Burton grade 1 to 5. Patients underwent twice-weekly 20-minute sessions of LED therapy for 4 weeks, alternating between the blue (415 nm) and near-IR (830 nm) heads. No other treatment was allowed. Results were assessed and compared with the baseline values at 1, 4 and 8 weeks post-treatment. RESULTS: Six individuals failed to complete the study. Eleven individuals showed improvement ranging from 0% to 83.3%. A downward shift in the Burton grade was seen overall. Non-inflammatory lesion counts increased in four patients, but improved in the other seven by an average of 48.8%. No adverse effects were reported. CONCLUSIONS: The combination therapy for acne produced results which were less effective in the reduction of inflammatory lesions than those achieved with the previously reported blue/red combination. Further study with a much larger patient population is warranted.