[Tratamientos estéticos. Posición de la Academia Nacional de Medicina de México].

In Mexico there is a proliferation of "centers for aesthetic medicine" that offer different treatments with laser beam, mesotherapy and hyaluronic acid and botulinum toxin injections. In numerous centers of this type, offered and performed by medical personnel that are neither trained or certified to ensure the quality of services. The National Academy of Medicine of Mexico and the National Normative Council for Medical Specialties (CONACEM) communicate their posture on this matter.

En México existe una proliferación de "centros de medicina estética" que ofrecen tratamientos diversos con rayos láser, mesoterapia, ácido hialurónico e inyecciones con toxina botulínica por personal médico que no está capacitado ni certificado para asegurar la calidad de los servicios. La Academia Nacional de Medicina y el Comité Normativo Nacional de Consejos de Especialidades Médicas (CONACEM) comunican su postura al respecto.

Methods for the assessment of the efficacy of products and slimming treatments for cellulite according to the Italian Interdisciplinary Group for the standardization of efficacy tests on cosmetic products.

Cellulite is a very common skin alteration with a complex pathogenesis; different degrees of severity of cellulite can be observed in most part of people after puberty, and numerous cosmetic or more invasive treatments have been proposed, with variable efficacy. Since reproducible methods of evaluation of the effectiveness of cellulite treatments are lacking, the purpose of our group was to define and set general testing principles for evaluating the efficacy of slimming products and treatments/remodeling methods for cellulite, to achieve a delineation of reliable and reproducible research steps following a well-designed and scientifically valid methodology. After a careful review of literature and textbooks and according to personal experience, we defined assessment protocols based on clinical and instrumental tools. In order to make studies reliable, reproducible and safe, a protocol standardization is needed. The sponsor is responsible for assuring quality and information concerning the product under investigation; moreover, investigators should be experienced on cellulite evaluation and treatment, and, finally, the duration and modalities of application of the product should be specified. A treated VS non treated area comparison can be performed, to evaluate the severity of cellulite and the clinical outcomes of the treatment. Besides clinical evaluation, instrumental methods should always be implemented to provide objective data for treatment outcome.

Position paper on mesotherapy.

Mesotherapy is a controversial cosmetic procedure which has received publicity among the lay people, in the internet and in the media. It refers to minimally invasive techniques which consist of the use of intra- or subcutaneous injections containing liquid mixture of compounds (pharmaceutical and homeopathic medications, plant extracts, vitamins and other ingredients) to treat local medical and cosmetic conditions. This position paper has examined the available evidence and finds that acceptable scientific evidence for its effectiveness and safety is lacking. IADVL taskforce, therefore would like to state that the use of this technique remains controversial at present. Further research and well-designed controlled scientific studies are required to substantiate the claims of benefit of this mode of therapy.

Glycolic acid peels versus amino fruit acid peels for acne.

INTRODUCTION: Chemical exfoliation resulting in the reduction of keratotic plugs serves as a second-line treatment used as an adjunct to anti-acne agents. This study was designed to compare the therapeutic effects of glycolic acid (GA) peels and amino fruit acid (AFA) peels in patients with acne vulgaris. METHODS: In this single-blind, randomized, right-left comparison study, 24 patients received 12 serial peels (GA and AFA, at concentrations from the lowest to the highest) on the two halves of the face at 2-week intervals for 6 months. In addition, cutaneous tolerability assessments during the applications and the patient preference test between both peeling methods at the end of the study were performed. RESULTS: There was a statistically significant decrease in the number of non-inflamed lesions with GA following the first month and with AFA following the second month (p < 0.05). The decrease in the number of inflamed lesions was statistically significant with GA at the end of the fifth and sixth months and with AFA only at the end of the fifth month (p < 0.05). When the two applications were compared with each other, there was not a statistically significant difference in terms of non-inflamed and inflamed lesions (p > 0.05). During the application, it was observed that AFA peels caused fewer problems than GA peels did. AFA concentrations were increased more rapidly and more sessions were performed at the highest concentration of AFA. CONCLUSION: Based on the results of this study, we can state that both GA and AFA peels are efficacious for comedonal acne. And, compared to a GA peel, an AFA peel is less irritating and better tolerated.

Survey of the cosmetic use of lasers and other strong optical radiation sources.

A survey was undertaken regarding the extent to which optical radiation is used in cosmetic treatments and the compliance with national regulations. Questionnaires were sent to 65 clinics, and 23 of these were later inspected. Only one of 41 class 4 lasers had been reported to the authorities according to the regulations prior to the survey. Among sources other than lasers, intense pulsed light (IPL) sources were the most frequent. Although qualified health personnel should be in charge of the treatment, it was observed that 30% of the clinics did not fulfil this requirement. Deviations with respect to personnel training, availability of written procedures, protective equipment and warning signs were frequently observed. The results give rise to concern about the safety of patients and employees.

Standard guidelines of care for acne surgery.

UNLABELLED: Acne surgery is the use of various surgical procedures for the treatment of postacne scarring and also, as adjuvant treatment for active acne. Surgery is indicated both in active acne and post-acne scars. PHYSICIANS' QUALIFICATIONS: Any Dermatologist can perform most acne surgery techniques as these are usually taught during postgraduation. However, certain techniques such as dermabrasion, laser resurfacing, scar revisions need specific "hands-on" training in appropriate training centers. FACILITY: Most acne surgery procedures can be performed in a physician's minor procedure room. However, full-face dermabrasion and laser resurfacing need an operation theatre in a hospital setting. ACTIVE ACNE: Surgical treatment is only an adjunct to medical therapy, which remains the mainstay of treatment. Comedone extraction is a process of applying simple mechanical pressure with a comedone extractor, to extract the contents of the blocked pilosebaceous follicle. Superficial chemical peel is a process of applying a chemical agent to the skin, so as to cause controlled destruction of the epidermis leading to exfoliation. Glycolic acid, salicylic acid and trichloroacetic acid are commonly used peeling agents for the treatment of active acne and superficial acne scars. CRYOTHERAPY: Cryoslush and cryopeel are used for the treatment of nodulocystic acne. Intralesional corticosteroids are indicated for the treatment of nodules, cysts and keloidal acne scars. Nonablative lasers and light therapy using Blue light, non ablative radiofrequency, Nd:YAG laser, IPL (Intense Pulsed Light), PDT (Photodynamic Therapy), pulse dye laser and light and heat energy machines have been used in recent years for the treatment of active inflammatory acne and superficial acne scars. Proper counseling is very important in the treatment of acne scars. Treatment depends on the type of acne scars; a patient may need more than one type of treatment. Subcision is a treatment to break the fibrotic strands that tether the scar to the underlying subcutaneous tissue, and is useful for rolling scars. Punch excision techniques such as punch excision, elevation and replacement are useful for depressed scars such as ice pick and boxcar scars. TCA chemical reconstruction of skin scars (CROSS) (Level C) is useful for ice pick scars. Resurfacing techniques include ablative methods (such as dermabrasion and laser resurfacing), and nonablative methods such as microdermabrasion and nonablative lasers. Ablative methods cause significant postoperative changes in the skin, are associated with significant healing time and should be performed by dermatosurgeons trained and experienced in the procedure. Fillers are useful for depressed scars. Proper case selection is very important in ensuring satisfactory results.

Summary: use of class 3b and class 4 lasers and intense pulsed light sources for cosmetic procedures in non-medical settings

INTRODUCTION: Body image has always preoccupied people across time and cultures. Today, the search for beauty can be fulfilled with high-power technologies that are relatively easy to use, such as Class 3b and Class 4 lasers and intense pulsed light (IPL) sources. Lasers are devices that amplify light, emitting it in a narrow, coherent optical beam; the beam produced is near-monochromatic, the particles all move in the same direction, and the waves are in phase with one another. Intense pulsed light is based on different physical and technological principles. Unlike lasers, IPL sources emit polychromatic light (non-coherent, between 500 and 1,200 nm), and selected wavelengths are obtained by means of filters. These technologies are used for various cosmetic purposes and applications, including some that clearly come under activities reserved to physicians, while others fall into the grey areas surrounding medicine. Based on the definitions of the different fields of medical activity and on the laws and regulations governing the practice of medicine, this report has limited its scope to examining laser and IPL procedures that do not require medical diagnosis and that may be performed in Québec by operators other than physicians or health professionals, without medical supervision. This report does not purport to determine what does and does not lie within the scope of medicine. Rather, it focuses on the risks inherent in these technologies and on the qualifications required to use them, by taking hair removal as a base case and by dealing more briefly with skin resurfacing and tattoo removal, without ruling on the field of activity to which these practices belong. RESEARCH METHODS: Medline (National Library of Medicine) via PubMed and the Cochrane Library were searched. The grey literature was also examined to take into account the contextual aspects that prompted the request for this report, especially the legal and regulatory provisions framing the use of lasers and IPL by non-physician operators in various countries and regions. In addition, local experts were consulted to validate the contextual evidence and the applicability of the ensuing recommendations. These experts are key actors in the following organizations: Association des dermatologistes du Québec; Collège des médecins du Québec; Comité sectoriel de la main-d'œuvre des services de soins personnels [sector committee on personal services workers]; Ministère de l'Éducation, du Loisir et du Sport; Ministère de l'Emploi et de la Solidarité sociale; and Ministère de la Santé et des Services sociaux. CONCLUSION: Analysis of the scientific and contextual evidence leads to these findings: Class 3b and Class 4 lasers and IPL sources are high-power technologies entailing risks for operators and their customers. The use of these technologies leads to adverse effects that, although minor and transient for the most part, may in some cases be serious; however, scientific evidence does not allow us to determine their frequency or severity, or to link them with the types of professionals using them. Some cosmetic procedures may overlap with activities reserved to physicians when these. procedures are applied to areas of the skin with an underlying medical condition or with the risk of complications requiring medical expertise. Current Canadian safety standards regulate the sale and importation of these devices and their use in health-care facilities, and the safe use of lasers is governed by laws and regulations intended to protect workers' health and safety in all work settings. However, Québec has no law or regulation to protect the health and safety of the public undergoing laser or IPL procedures in non-medical settings. The use of Class 3b and Class 4 lasers and IPL sources is widespread in beauty care centres, but the specific types of devices used are not known. There is no professional order regulating the practice of estheticians or other types of personnel working in the personal services sector and likely to use laser or IPL devices, and the Office des professions du Québec has already denied the application by the Association des électrolystes du Québec to establish a professional order. The Comité sectoriel de la main-d'œuvre des services de soins personnels and the Ministère de l'Éducation, du Loisir et du Sport have already developed their own non-mandatory vocational training programs in laser hair removal, but these programs do not cover other cosmetic laser applications or the use of IPL. The Act respecting Workforce Vocational Training and Qualification (R.S.Q., c. F-5) could fill this regulatory gap in part by standardizing the required occupational skills, establishing vocational training and qualification programs, and determining occupational eligibility requirements for laser or IPL operators working in non-medical settings. In light of these findings, this report is not able to rule either on the safety of laser or IPL procedures by non-physician operators working without medical supervision or on the scope of activities that could be authorized to them in the Québec context. However, given that these technologies present hazards and may lead to adverse effects that are potentially serious when used for cosmetic procedures, and given that there is a serious possibility of interference with the field of medicine, AETMIS has reached the following conclusions, which define the major issues to be dealt with: The boundary between the procedures restricted to the field of medicine and the cosmetic procedures that may be performed by non-physician operators must be clearly established.

Utilisation des lasers de classe 3b et 4 et de la lumière intense pulsée à des fins esthétiques dans un contexte non médical / Use of class 3b and 4 lasers and intense pulsed light for aesthetic purposes in a non-medical context

INTRODUCTION: Body image has always preoccupied people across time and cultures. Today, the search for beauty can be fulfilled with high-power technologies that are relatively easy to use, such as Class 3b and Class 4 lasers and intense pulsed light (IPL) sources. Lasers are devices that amplify light, emitting it in a narrow, coherent optical beam; the beam produced is near-monochromatic, the particles all move in the same direction, and the waves are in phase with one another. Intense pulsed light is based on different physical and technological principles. Unlike lasers, IPL sources emit polychromatic light (non-coherent, between 500 and 1,200 nm), and selected wavelengths are obtained by means of filters. These technologies are used for various cosmetic purposes and applications, including some that clearly come under activities reserved to physicians, while others fall into the grey areas surrounding medicine. Based on the definitions of the different fields of medical activity and on the laws and regulations governing the practice of medicine, this report has limited its scope to examining laser and IPL procedures that do not require medical diagnosis and that may be performed in Québec by operators other than physicians or health professionals, without medical supervision. This report does not purport to determine what does and does not lie within the scope of medicine. Rather, it focuses on the risks inherent in these technologies and on the qualification

Measuring key parameters of intense pulsed light (IPL) devices.

BACKGROUND: Unlike medical lasers, intense pulsed light (IPL) devices are largely unregulated and unclassified as to degree of safety hazard. With the exception of most of the USA, the United Kingdom and parts of Europe, the Far East and Australia, the sale of IPLs is generally unrestricted, with the majority being sold into the beauty therapy and spa markets. Standards are only imposed on manufacturers for technical performance data and operating tolerances determined by CE-compliance under electrical safety standards or the EU Medical Device Directive. Currently, there is no requirement for measurement of key IPL performance characteristics. OBJECTIVE: To identify the key IPL parameters, emphasize their importance in terms of safe and effective treatment and provide examples of preliminary measurement methods. These measurements can highlight changes in an IPL device's performance, improving patient safety and treatment efficacy. METHODS: Five key parameters were identified as having an important role to play in the way light interacts with the skin, and therefore an important role in patient safety and effective treatment. Simple methods were devised to measure the parameters, which include fluence, pulse duration, pulse profile, spectral output and time-resolved spectral output. RESULTS: The measurement methods permitted consistent and comparable measurements to be made by two of the authors at working clinic locations on 18 popular IPL devices and allowed assessment of output variations. Results showed discrepancies between the measured IPL device outputs and those values displayed on the system or claimed by the manufacturers. The importance of these discrepancies and their impact is discussed. CONCLUSIONS: This study, of 18 popular devices in regular daily use in England and Wales, provides example methods for measuring key IPL device parameters and highlights the need for regular measurement of at least those five key parameters measured in this study. These methods can help service technicians to check performance and eliminate device malfunction.

[Soft-tissue infections due to non-tuberculous mycobacteria following mesotherapy. What is the price of beauty]. / Infecciones en tejidos blandos por micobacterias no tuberculosas secundarias a mesoterapia. 'Cuánto vale la belleza?

INTRODUCTION: Mesotherapy is widely used In Latin America for cosmetic purposes, particularly in obese individuals. We describe the clinical and epidemiological characteristics, microbiological diagnosis, treatment and follow-up of patients from Caracas (Venezuela) with soft tissue infection caused by non-tuberculous mycobacteria following mesotherapy. METHODS: Between March 2002 and December 2003, we evaluated 49 cases of skin and soft tissue infection following mesotherapy. Specimens obtained from the lesions and 15 products used in the mesotherapy procedure were cultured for the presence of non-tuberculous mycobacteria. Isolated mycobacteria were identified by PCR restriction fragment length polymorphism analysis of the hsp65 gene. RESULTS: Infection by non-tuberculous mycobacteria was confirmed in 81.6% of the 49 cases. Mycobacterium abscessus and M. fortuitum were the most common species, but M. chelonae, M. peregrinum, M. simiae and a new species that was designated "M. cosmeticum" were also isolated. Patients were treated with species-specific antibiotic agents for 3 to 18 months. Investigation into the source of the infection revealed that 21 patients were clustered within 3 different outbreaks and two products were found to be contaminated with M. fortuitum and M. abscessus, respectively. CONCLUSIONS: Physicians should be alerted to the possibility of infection by non-tuberculous mycobacteria in patients with a history of mesotherapy who develop late-onset skin and soft tissue infection, particularly if they do not respond to conventional antibiotic treatment.

Infecciones en tejidos blandos por micobacterias no tuberculosas secundarias a mesoterapia. ¿Cuánto vale la belleza? / Soft tissue infections due to non-tuberculous mycobacteria following mesotherapy. What is the price of beauty?

Introducción. La mesoterapia se utiliza mucho en Latinoamérica con fines cosméticos, especialmente en pacientes con obesidad. En este estudio se describen las características clínicas y epidemiológicas, el diagnóstico microbiológico, el tratamiento y el seguimiento de infecciones por micobacterias no tuberculosas en un grupo de pacientes en Caracas (Venezuela) con antecedentes de mesoterapia. Metodología. Entre marzo de 2002 y diciembre de 2003 se evaluaron 49 pacientes con infección en la piel y tejidos blandos secundaria a mesoterapia. Se tomaron muestras de las lesiones para el aislamiento de micobacterias y se elaboró una ficha clínica. Además, se analizaron 15 productos utilizados en mesoterapia. Las micobacterias aisladas fueron identificadas a través del polimorfismo de fragmentos de restricción del gen hsp65. Resultados. De los 49 pacientes evaluados, en el 81,6% se confirmó una infección por micobacterias no tuberculosas. Las especies más comunes fueron Mycobacterium abscessus y M. fortuitum pero también se aislaron M. chelonae, M. peregrinum, M. simiae y una nueva especie que fue designada M. cosmeticum. Los pacientes recibieron tratamiento específico para cada especie durante un período de 3 hasta 18 meses. La investigación de la fuente de infección reveló que 21 pacientes estaban agrupados en tres brotes y se encontraron dos productos contaminados, uno con M. fortuitum y otro con M. abscessus. Conclusiones. Los médicos deben estar atentos ante aquellos pacientes con antecedentes de mesoterapia que desarrollen tardíamente lesiones en piel y tejidos blandos, que no respondan al tratamiento antimicrobiano convencional, ya que éstas podrían ser causadas por micobacterias no tuberculosas (AU)

Introduction. Mesotherapy is widely used In Latin America for cosmetic purposes, particularly in obese individuals. We describe the clinical and epidemiological characteristics, microbiological diagnosis, treatment and follow-up of patients from Caracas (Venezuela) with soft tissue infection caused by non-tuberculous mycobacteria following mesotherapy. Methods. Between March 2002 and December 2003, we evaluated 49 cases of skin and soft tissue infection following mesotherapy. Specimens obtained from the lesions and 15 products used in the mesotherapy procedure were cultured for the presence of non-tuberculous mycobacteria. Isolated mycobacteria were identified by PCR restriction fragment length polymorphism analysis of the hsp65 gene. Results. Infection by non-tuberculous mycobacteria was confirmed in 81.6% of the 49 cases. Mycobacterium abscessus and M. fortuitum were the most common species, but M. chelonae, M. peregrinum, M. simiae and a new species that was designated "M. cosmeticum" were also isolated. Patients were treated with species-specific antibiotic agents for 3 to 18 months. Investigation into the source of the infection revealed that 21 patients were clustered within 3 different outbreaks and two products were found to be contaminated with M. fortuitum and M. abscessus, respectively. Conclusions. Physicians should be alerted to the possibility of infection by non-tuberculous mycobacteria in patients with a history of mesotherapy who develop late-onset skin and soft tissue infection, particularly if they do not respond to conventional antibiotic treatment (AU)