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.

Development and Validation Clinician and Patient Reported Photonumeric Scales to Assess Buttocks Cellulite Severity.

BACKGROUND: The Clinician Reported Photonumeric Cellulite Severity Scale (CR-PCSS) and Patient Reported PCSS (PR-PCSS) are newly developed tools for assessing cellulite severity. OBJECTIVE: To report on the reliability, validity, and ability to detect a change in cellulite severity on the buttocks of adult women with the CR-PCSS and PR-PCSS. MATERIALS AND METHODS: Content validity of both scales was established through concept elicitation and cognitive interviews. Test-retest reliability was evaluated, and intra-rater (both scales) and inter-rater (CR-PCSS only) reliability were estimated using intraclass correlation coefficients (ICCs) for agreement and consistency. Ability to detect a change was determined using the Subject-Global Aesthetic Improvement Scale (GAIS) or Investigator-GAIS as anchors. RESULTS: For the CR-PCSS (n = 6) at baseline and Day 2, the mean interrater ICCs were ≥0.70 and mean intrarater ICCs (95% confidence interval [CI]) were ≥0.81 (0.72-0.90) for both buttocks. For the PR-PCSS (n = 99) at baseline and Day 14, the mean test-retest reliability ICCs (95% CI) were ≥0.86 (0.79-0.91) for both buttocks. A clinically meaningful change was 1.0 point on the PR-PCSS and 1.0 on the CR-PCSS. CONCLUSION: The CR-PCSS and PR-PCSS reliably assess cellulite severity of the buttocks and can detect a clinically meaningful change after treatment for cellulite.

Randomized, Controlled, Multicentered, Double-Blind Investigation of Injectable Poly-L-Lactic Acid for Improving Skin Quality.

BACKGROUND: Poly-L-lactic acid (PLLA) is an injectable filler used for restoring facial fat volume loss. OBJECTIVE: To evaluate the effect of repeated PLLA injections on skin quality. METHODS: Forty healthy women were enrolled in this randomized, controlled, double-blind, multicenter study. Eligible subjects received 3 treatments every 4 weeks with either PLLA (treatment group) or saline (control group) injections, into both sides of the face. Follow-up visits were at 6, 9, and 12 after the last treatment. Assessments included biophysical measuring instruments, live ratings, patient questionnaires, and rating of standardized pictures by a blinded evaluator. RESULTS: At the 12-month follow-up, there was a statistically significant increase of skin elasticity and hydration in PLLA-treated subjects and a decrease in transepidermal water loss in both groups. Pigmentation, erythema, and pore size were significantly decreased, whereas radiance and smoothness were significantly increased at 12 months per blinded investigator rating in this group. No treatment-related adverse events occurred. CONCLUSION: Repeated PLLA treatments may improve skin quality in a time-dependent manner.

Collagenase Clostridium Histolyticum for the Treatment of Edematous Fibrosclerotic Panniculopathy (Cellulite): A Randomized Trial.

BACKGROUND: Edematous fibrosclerotic panniculopathy (EFP; cellulite) is associated with thickening and contraction of collagen-rich subdermal septae. Collagenase clostridium histolyticum (CCH) may disrupt collagen-rich septae. OBJECTIVE: To evaluate the safety and efficacy of CCH for treatment of EFP. MATERIALS AND METHODS: In a randomized, double-blind study, women with moderate or severe EFP of the buttocks or posterolateral thighs (i.e., Clinician Reported Photonumeric Cellulite Severity Scale [CR-PCSS] and Patient Reported Photonumeric Cellulite Severity Scale [PR-PCSS] ratings of 3 to 4, and Hexsel Cellulite Severity Scale score ≤13) received up to 3 treatment sessions (Days 1, 22, and 43) of subcutaneous CCH 0.84 mg or placebo injections. End points included the percentage of 2-level and 1-level composite responders (i.e., had ≥2-level or ≥1-level improvement in CR-PCSS and PR-PCSS) at Day 71. RESULTS: Three hundred seventy-five women (mean age, 46.5 years; 86.4% white) were randomly assigned to CCH (n = 189) or placebo (n = 186). At Day 71, the percentages of 2-level and 1-level composite responders were greater with CCH (10.6% and 44.6%, respectively) versus placebo (1.6% and 17.9%; p < .001 for both). The most common adverse events were injection-site related. CONCLUSION: CCH significantly improved EFP appearance versus placebo; further evaluation of CCH for EFP (cellulite) is warranted.

Efficacy of combination therapy with efinaconazole 10% solution and 1064 nm Nd:YAG laser for treatment of toenail onychomycosis.

BACKGROUND: Onychomycosis is a common but difficult to treat nail disorder. Treatment strategies thus far have included oral and topical antifungals, surgical treatment and recently lasers have emerged as a therapeutic modality. OBJECTIVE: The objective of this study was to assess whether efinaconazole together with laser would result in greater clinical and mycologic cure and lower rate of relapse compared to efinaconazole alone. METHODS: Thirty subjects were randomized to either self-apply efinaconazole 10% once daily for 48 weeks, or follow the same treatment plan but also receive six treatments with a 1064 nm Nd: YAG laser every 4 weeks. The primary endpoint was to assess the proportion of subjects who achieved complete cure at week 52. RESULTS: The combination therapy group showed significantly quicker mycological cure at the 48- and 52-week follow-up. CONCLUSION: Both efinaconazole and combination with laser were efficacious treatment, but the combination therapy leads to quicker resolution with fewer rate of relapse.

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.

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.

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.

New Insight Into the Pathophysiology of Hair Loss Trigger a Paradigm Shift in the Treatment Approach.

Hair loss affects millions of men and women of all ages and ethnicities, impacting appearance, social interactions, and psycho-emotional well-being. Although a number of options are available, they are limited, carry a potential risk of side effects, and none have proven to be comprehensive for treatment of hair loss. Across the spectrum of hair loss disorders, there has long been a segmentation into distinct mechanisms, driving the main trend in current therapeutics to focus on targeting single molecules or pathways. However, research points to similar dysregulation of intrinsic signaling pathways within follicle physiology that span the hair loss disorder spectrum - with a common inflammatory component identified in most hair loss pathogenesis, including that of androgenetic alopecia (AGA).

J Drugs Dermatol. 2017;16(11 Suppl):s135-140.

Understanding the Shape of Forehead Lines.

Background: Individualized neuromodulator injections of the forehead are increasingly important to maximize patient safety and satisfaction and to yield the best aesthetic outcome. To assess the location of maximal muscle contraction, it would beneficial to relate the shape and location of the forehead lines to the morphology of the underlying frontalis muscle.

Materials and Methods: We investigated the shape of forehead lines and their relationship to the morphology of the underlying frontalis muscle using anatomic dissection in a sample of 31 human body donors, with a mean age at death of 77.2 ± 13.2 years (range, 47-93) of which n=29 (93.5%) were of Caucasian and n=2 (6.5%) of African-American ethnicity and of which n=16 (51.6%) were females (n=15 males; 48.4%).

Results: Horizontal forehead lines were classified into straight n=13 (41.9%) and wavy n=18 (58.1%) lines. The presence of wavy forehead lines (as compared to straight lines) was significantly related to the presence of a midline aponeurosis (r = 0.69; P less than 0.001) and to a greater muscle fascicle angle (12.67 ± 2.60° vs 10.18 ± 2.12°) (r = 0.47; P less than 0.001), but was not statistical significantly influenced by age, gender, or ethnicity (all P greater than 0.05).

Conclusion: According to the shape of the forehead lines, physicians can appreciate the morphology of the underlying frontalis muscle. This understanding will facilitate more accurate neuromodulator injections and a better aesthetic outcome. It may also result in decreased dosages and increased injection intervals for maximal patient safety. LEVEL OF EVIDENCE: IV

J Drugs Dermatol. 2017;16(5):471-477.

A 12-week clinical and instrumental study evaluating the efficacy of a multisource radiofrequency home-use device for wrinkle reduction and improvement in skin tone, skin elasticity, and dermal collagen content.

This study was performed in order to evaluate the safety and efficacy of a new handheld home-use multisource radiofrequency device on facial rejuvenation. Forty-seven male and female subjects were enrolled. All subjects received a NEWA® 3DEEP™ home-use device (EndyMed Medical, Caesarea, Israel) to be used on facial skin three times per week for the first four weeks and then reduced to two times per week for the following eight weeks. Assessments included expert clinical grading for efficacy, instrumental evaluation, image analysis, and photography. Forty-five subjects completed the study; all subjects reported the treatment to be painless with only mild erythema lasting up to 15 minutes post-treatment. No other adverse events were reported. Statistically significant improvements were noted in the appearance of marionette lines, skin brightness, elasticity, firmness, lift (facial), lift (jawline), texture/smoothness, tone, and radiance/luminosity by expert visual assessment. Statistically significant improvements in skin firmness and elasticity were found using a Cutometer MPA 580, as well as in collagen and hemoglobin content of the skin using a SIAscope. The results of this study indicate that the NEWA® multisource radiofrequency home-use device is effective in self-administered skin rejuvenation.

The Facial Adipose System: Its Role in Facial Aging and Approaches to Volume Restoration.

BACKGROUND: Volume loss in facial adipose tissue plays a critical role in the aesthetics of facial aging. Furthermore, the facial adipose system is a complex network of distinct compartments, and a detailed understanding of these compartments is essential for optimal facial volume restoration. OBJECTIVE: To review the facial adipose system, age-related changes, and the role of volume restoration products for facial rejuvenation. METHODS: Publications including deceased donors' dissection studies and more recent studies using computed tomography were reviewed to provide an up-to-date understanding of the facial adipose system anatomy and age-related changes. Current volume restoration treatment options including hyaluronic acid, calcium hydroxylapatite, and poly-L-lactic acid are discussed. RESULTS: Facial aging is associated with volume loss in superficial and deep adipose compartments, including those of the forehead, cheek, lip, chin, and jowl areas. Volume restoration products can be used to address the age-related changes of the facial adipose compartments. CONCLUSION: Understanding the complex network of facial adipose compartments and their age-related changes allows for the optimal use of injectable volume restoration products for facial rejuvenation that can be customized to the anatomical needs of each patient.

A randomized, controlled clinical study to investigate the safety and efficacy of acoustic wave therapy in body contouring.

BACKGROUND: There is an increased demand for the reduction of localized adipose tissue by noninvasive methods. OBJECTIVE: The objective of this study was to determine the safety and efficacy of noninvasive lipolysis of excess adiposities overlying the lateral thigh region using acoustic wave therapy (AWT). This study incorporates 2 mechanical waves with varying properties in the same session: radial and planar AWT. METHODS AND MATERIALS: The treatment was performed using AWT on the lateral thigh areas of 15 female patients. The study was performed using the planar and radial pulse handpieces, with 8 sessions performed within 4 weeks. Follow-up visits were performed 1, 4, and 12 weeks after the last treatment. RESULTS: Reduction in both thigh circumference and subcutaneous fat layer thickness, measured through ultrasound, was observed. CONCLUSION: This study demonstrates that AWT is safe and efficacious for the treatment of localized adiposities in the saddlebag area. However, the results obtained were not statistically significant. Larger studies will be needed to further access the effects of AWT on thigh circumference reduction. Furthermore, the authors also found an improvement in the appearance of both cellulite and skin firmness after the treatments.

HYC-24L Demonstrates Greater Effectiveness With Less Pain Than CPM-22.5 for Treatment of Perioral Lines in a Randomized Controlled Trial.

OBJECTIVE: This trial compares the effectiveness and safety of HYC-24L (Juvéderm Ultra XC; Allergan plc, Dublin, Ireland) (24 mg/mL of hyaluronic acid, 0.3% lidocaine) and CPM-22.5 (Belotero Balance; Merz Aesthetics, Raleigh, NC) (22.5 mg/mL of hyaluronic acid) for the treatment of perioral lines. MATERIALS AND METHODS: Men and women aged 35 years or older with moderate-to-severe perioral lines were recruited for this randomized controlled, rater-blinded, 2-arm trial. The primary endpoint was a comparison of rater-assessed responder rates by the validated 4-point Perioral Lines Severity Scale at Month 6; responders were those who showed a ≥1 point improvement. A secondary endpoint was subject-assessed change in perioral lines measured by the Global Assessment of Change Scale. RESULTS: A total of 136 subjects received treatment and 132 completed the trial (mean age: 58 ± 8 years). Total volume injected was 1.18 mL (HYC-24L) and 1.32 mL (CPM-22.5). At Month 6, a significantly greater proportion of HYC-24L subjects responded to treatment (87%) than CPM-22.5 subjects (72%) (p < .04). At all time points, HYC-24L subjects reported significantly greater improvement in their perioral lines than CPM-22.5 subjects, with the greatest difference at Month 6. No unexpected adverse events occurred. CONCLUSION: HYC-24L subjects showed a higher response rate and a greater improvement in their perioral lines than CPM-22.5 subjects for up to 6 months.

Bipolar and multipolar radiofrequency.

BACKGROUND: The increased demand for anti-aging treatments over the past decade has fueled the development of multimodality devices. This allows for more efficacious treatment of dermal defects, excess adiposity, and skin laxity. Radiofrequency (RF) devices are constantly evolving and consequently adding multiple indications for their use. In this article, the authors focus on bipolar and multipolar RF modalities. OBJECTIVE: The objective was to review, summarize, and evaluate the key studies of procedural therapies using bipolar and multipolar RF technologies. METHODS: Studies selected for evaluation had clear statements of purpose, patient selection, follow-up evaluations, previous and concurrent medications, treatment parameters, methods for evaluating results, and adverse effects. All studies were complete and published in peer-reviewed journals. RESULTS AND CONCLUSION: With their unique mechanism of action, bipolar and multipolar RF devices remain versatile treatment options associated with minimal downtime and pain compared with monopolar RF and other nonablative modalities. Proper patient selection and education along with an experienced treating physician is crucial in achieving patient satisfaction and results. It is important that larger studies are conducted to provide data on upcoming devices. Review of the literature provides a starting point for physicians seeking to treat patients safely and effectively with newer devices.

Consensus for sclerotherapy.

BACKGROUND: The American Society for Dermatologic Surgery (ASDS) periodically develops consensus documents for its members concerning various aspects of dermatologic surgery. Unwanted and painful leg veins are a very widespread problem. Many advances in sclerotherapy of varicose and telangiectatic leg veins have occurred since the previous consensus documents. OBJECTIVE: In 2013, the ASDS Board of Directors voted to have a committee of experts in the field to develop consensus documents on sclerotherapy. MATERIALS AND METHODS: An expert panel reviewed the literature on sclerotherapy and discussed the findings. A consensus was reached with evidence-based recommendations on diagnostic evaluation and treatment of varicose and telangiectatic leg veins. RESULTS: The consensus documents include discussion of indications for treatment, patient selection, contraindications, diagnostic testing, treatment approaches, use of compression, and expected outcome. Common sclerosants and their mechanisms of action, advantages and disadvantages of foam sclerotherapy, and minimizing and treating complications are presented. CONCLUSION: The ASDS consensus documents on sclerotherapy will be helpful in educating their members on safe and effective sclerotherapy of varicose and telangiectatic leg veins.

Radiofrequency: an update on latest innovations.

As the aging population in our society continues to grow, new technologies and procedures promising a more youthful appearance are continuously sought. The utilization of radiofrequency technology remains a novel method for the treatment of many aesthetic and medical dermatological indications. Innovative applications are constantly identified, expanding treatment options for various patient concerns including aging of the hands, cellulite, non-invasive lipolysis, and postpartum skin laxity. Non-invasive treatments are ideal for busy patients seeking minimal recovery time and so called lunch-time procedures. Furthermore, new developments in treatment devices enhance efficacy while decreasing patient discomfort.

Home-based wrinkle reduction using a novel handheld multisource phase-controlled radiofrequency device.

BACKGROUND: In the last decade, energy-based aesthetic treatments, using light, radiofrequency (RF), and ultrasound, have gained scientific acceptance as safe and efficacious for non-invasive treatment for aesthetic skin disorders. The phase-controlled multisource radiofrequency technology (3DEEP™), which is based on the simultaneous use of multiple RF generators, was proven to allow significant pigment-independent dermal heating without pain or the need of epidermal cooling. This study was performed in order to evaluate the efficacy and safety of a new handheld device delivering multisource radiofrequency to the skin for wrinkle reduction and skin tightening in the home setting. PATIENTS AND METHODS: A total of 69 participants (age 54.3 years ± 8.09; age range 37-72 years) were enrolled in the study after meeting all inclusion/exclusion criteria (100%) and providing informed consent. Participants were provided with the tested device together with a user manual and treatment diary, to perform independent treatments at home for 4 weeks. The tested device, (Newa™, EndyMed Medical, Cesarea, Israel) emits 12 W of 1Mhz, RF energy through six electrodes arranged in a linear fashion. Independent control of RF polarity through each one of the 6 electrodes allows significant reduction of energy flow through the epidermis with increased dermal penetration. Participants were instructed to perform at least 5 treatments a week, for one month. Four follow-up visits were scheduled (once a week) during the period of independent treatments at home, following 4 weeks of home treatments, 1 month follow-up visit (1 month after treatment end) and at 3 months follow-up (3 months following treatment end). Analysis of pre-and post treatment images was conducted by three uninvolved physicians experienced with the Fitzpatrick Wrinkle and Elastosis Scale. Fitzpatrick Wrinkle and Elastosis score of each time point (4 weeks following home use treatments; 1 month follow-up, 3 months follow-up) was compared to baseline. Participants were asked a series of questions designed to explore usability concerns and level of satisfaction regarding the device use and subjective efficacy. RESULTS: Altogether, 62 subjects completed the study course and follow-up visits. No unexpected adverse effects were detected or reported throughout the independent treatment. All study participants did not experience any difficulties while operating the tested device for independent wrinkle reduction treatments. Photographic analysis of pre- and post-one month of independent home use treatments, and one and three months follow-up after end of treatment course, was conducted by three uninvolved board certified dermatologists. Analysis of results revealed improvement (downgrade of at least 1 score according to the Fitzpatrick scale) in 91.93%, 96.77%, and 98.39% of study subjects (according to the first, second, and third reviewer, respectively). Results were found to be statistically significant. The majority of study participants were very satisfied from the results of the independent treatment using the tested device for wrinkle reduction.

Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.