[Skin ageing-General features of facial ageing and therapeutic choices]. / Vieillissement cutané ­ Vieillissement facial global : orientation thérapeutique.

Correction of cutaneous and facial ageing is the key reason for consultations in aesthetic dermatology. This demand on the part of patients, which has become a social phenomenon, has increased thanks to the remarkable progress made in nonsurgical and less invasive therapies such as lasers, botulinum toxin and fillers. But in order to optimise their use and to provide a personalised touch, since each face ages differently, an overall facial analysis, both static and dynamic, is essential. Indeed, ageing is obviously not restricted to skin but also concerns underlying tissue such as muscle, fat tissue and supporting bone. In this article, we provide a clinical and physiopathological analysis of the ageing of skin and of the various types of ageing, whether chronological, hormonal or environmental, and we examine the major role played by UV radiation, as well as tobacco smoke and, in certain cases, pollution. The description of cutaneous ageing covers not only the face, in which photoaging is the predominant factor, but also ageing of skin throughout the rest of the body. Next we describe the general modes of facial ageing for the subcutaneous structures, first those of the skin muscles, which compensate for their atrophy by means of permanent hypercontraction that result in dynamic wrinkles, then those of fat tissue in which ptosis can occur, coupled in some cases with atrophy and loss of the fullness and harmonious facial curves of youth, and those of supporting bone structures and preferential areas of resorption, which are also where the most pronounced ageing of soft tissue is discernible. The upper third, middle and lower third of the face do not age in the same way and the relevant methods of correction thus differ. Finally, we briefly discuss the therapeutic choices available, taking into account the generally extremely reasonable expectations of patients, who tend to seek moderate and natural rejuvenation in keeping with their personality, as well as the elimination of negative expressions associated with ageing, and who want neither a rigid face nor aesthetic cloning.

[Post-inflammatory hyperpigmentation occuring after cosmetic procedures]. / Les hyperpigmentations post-inflammatoires succédant à des actes esthétiques.

A post-inflammatory hyperpigmentation (PIHP) can occur after cosmetic procedures such as chemical peels and lasers. Patients must be informed about this risk. Precautionary measures before, during and after the procedure can prevent or reduce the risk of PIHP. These procedures should not be done in summer on suntanned skin and patients have to be aware of the importance of an effective photoprotection. The PIHP occurs more frequently on dark-skinned patients, in Asians as well as in women with melasma history. In these cases, risk/benefit assessment of the cosmetic procedure is required: no risky procedure in patients at risk! PIHP can also be related to technical errors such as too high concentration or too long exposure time during peel procedure as well as excessive threshold fluences during laser procedure. If many therapies for PIHP damages can be proposed, patients feel frequently that they are not as quickly effective as they would like. Patients must be reassured as many PIHP resolve spontaneously. If photoprotection is always required, it is also possible to accelerate the pigmentation's clearing using the Kligman trio or the numerous topical lightening agents targeting several steps of the hyperpigmentation process. More invasive and expensive therapies such as peels, lasers, IPL or radiofrequency might be used for refractory cases. As a pigmentary relapse might occur after these procedures, the traditional Kligman trio should be always considered.

Propionibacterium acnes: an update on its role in the pathogenesis of acne.

In recent years, significant progress has been made in the understanding of the pathophysiological mechanisms of acne and the role of Propionibacterium acnes. With this review, the authors aim to provide an update on the current understanding of the role of P. acnes in the development of acne lesions and analysing the potential implications for future treatments. A total of 188 articles published between January 1980 and March 2013 were searched using key words such as acne, P. acnes, microbiology, Corynebacterium acnes, acne vulgaris, pathogenesis, antibiotic, vaccination and a combination of those key words. From those articles, 77 were analysed in depth. Recent data confirm that P. acnes has a strong proinflammatory activity and targets molecules involved in the innate cutaneous immunity, keratinocytes and sebaceous glands of the pilosebaceous follicle and leads to the development of comedones. Furthermore, the profile of its different strains may differ between healthy subjects and acne patients. The better understanding of the role of P. acnes may allow for new perspectives in the treatment of acne. Novel therapies should target molecules implicated in the activation of innate immunity, including toll-like receptors, protease-activated receptors and topical antimicrobial peptides; the latter may be an alternative to topical antibiotics and thus a solution for limiting bacterial resistance induced by topical macrolides. Vaccines may also be promising. However, the most appropriate candidate remains to be selected.

Development and evaluation of a Global Acne Severity Scale (GEA Scale) suitable for France and Europe.

BACKGROUND AND OBJECTIVE: Many acne grading methods exist; however, there is no agreed-upon standard. Our objective was to create and validate a reproducible acne assessment scale for rating the severity of juvenile facial acne suitable for use in France and Europe. METHODS: The scale we created described the different types of acne lesions in a manner similar to global assessment scales used in clinical trials. The scale was then validated by seven expert dermatologists in the field of acne [the Global Evaluation Acne (GEA) group] first on 34 photographic cases of Caucasian acne patients and second by clinical examination of 22 acne patients. RESULTS: There was good agreement in Investigators' assessments of acne both on photographs and patients (R = 0.8057; P < 0.0001, and R = 0.8437; P = 0.0015). CONCLUSION: The GEA Scale is a global scale validated both on photographs and acne patients which can be used either in clinical research or by the dermatologist in his office.

Inter-observer agreement on acne severity based on facial photographs.

BACKGROUND: The three-grade acne classification (mild, moderate, severe) is widely used to define the licensed indications of acne treatments, and for therapeutic decision-making in clinical practice, but its reproducibility has never been assessed. METHODS: Ten photographs of facial acne were scored independently by eight experts using the three-grade acne classification. We conducted a descriptive analysis of the results, based on graphical representation of the scores for each photograph. RESULTS: Inter-observer agreement on acne severity based on the three-grade acne classification was very poor. CONCLUSION: The classical three-grade acne classification is poorly reproducible. A new rating tool accompanied by a clinical description of each severity level would be extremely useful.

[Skin aging: clinicopathological features and mechanisms]. / Vieillissement cutané: aspects cliniques, histologiques et physiopathologiques.

Skin aging various considerably between individuals and depends on intrinsic factors such as age, oestrogen deficiency during menopause, and on extrinsic factors such as exposure to UV light and tobacco addiction. The clinical and histological characteristics of these different types of aging are described as well as the principle highly complex mechanisms that are involved. Treatment for skin aging has become the main reason why patients consult in cosmetic dermatology. For this reason, dermatologist should know how to analyse this condition and offer suitable therapeutic care that takes into account the aging of the subcutaneous tissue.

[Ablative and fractional lasers]. / Lasers ablatifs et lasers fractionnels.

The use of pulsed or scanning Carbon Dioxide, and pulsed Erbium-YAG lasers allows the programmable and reproducible photocoagulation of thin layers of the epidermis and superficial dermis. Thermal damage depends on the type of laser and is greater with CO(2) lasers. The degree of neocollagenesis is proportional to the thermal damage and is better with CO(2) lasers. Their main indication is the correction of photoaged facial skin but they can also be used for corrective dermatology, e.g. for scars and genodermatosis. Results are highly satisfactory but the technique is invasive and the patient experiences a social hindrance of around two weeks. Fractionated techniques treat 25% of the defective skin area at each session in noncontiguous microzones; four sessions are therefore necessary to treat the entire cutaneous surface. The treatment is given under topical anesthesia and is much less invasive, particularly with nonablative fractional laser treatment in which photothermolysis does not penetrate below the epidermis and/or the effects are slight, with no or very little social isolation. However, the results are much less satisfactory than the results of ablative laser and there is no firming effect. Other zones than the face can be treated. With the fractional CO(2) and Erbium ablative lasers, which have multiplied over the past 2 years, the much wider impacts cause perforation of the epidermis and there is a zone of ablation by laser photovaporization, with a zone of thermal damage below. The results are better in correcting photoaging of the face, without, however, achieving the efficacy of ablative lasers, which remain the reference technique. However, the effects are not insignificant, requiring at least 5 days of social isolation.

[Legal guidelines in esthetic dermatology]. / Le cadre légal en dermatologie esthétique et correctrice.

In cosmetic dermatology where treatment is not subject to a therapeutic need, the legal framework must be closely respected. For example, it is essential not to undertake procedures that go beyond the scope of one's training, an insurance policy is mandatory, and the patient's fully informed consent must be obtained. Information must be clear, objective and understandable to the patient, so discussion with him/her is of paramount importance. Fact sheets are useful but are not to be used instead of discussion. The patient should receive an estimate and be given two weeks t think things over before giving his/her informed consent. In the event of the patient filing a complaint, it is up to the clinician to prove that the patient received adequate information, hence the importance of keeping all documentary evidence such as an updated medical file and copies of all correspondence. The estimate must be signed by the patient but not the fact sheets, contrary to what has come to be common practice in some institutions. Insurance companies need a document signed by the patient. This may be a pre-printed form stating that the patient has been fully informed by the clinician and has given his//her informed consent to the planned procedure.

[Acute generalized exanthematous pustulosis induced by topical application of Algipan]. / Pustulose exanthématique aiguë généralisée induite par l'application d'Algipan.

BACKGROUND: In most cases, acute generalized exanthematous pustulosis (AGEP) is a drug reaction. Even if several systemic drugs have been reported to be a causative agent, this clinical case has rarely been observed with a topical treatment. We report here a case of AGEP after topical application of Algipan. PATIENTS AND METHODS: A 51-year-old man consulted us for a skin rash with fever which started 72 h earlier. His personal history consisted only of lumbar pain and he was not under any oral medication. The skin rash was initially limited to the left hand and the back but quickly spread to the entire skin with multiple non-follicular pustules emerging on widespread and inflamed erythema. No systemic treatment was being taken prior the eruption. Nevertheless, 3 days before the skin rash appeared, the patient had applied Algipan to the lumbar area with his left hand. The whole clinical presentation leads us to diagnose Algipan-induced AGEP. The clinical signs improved rapidly. Patch tests performed 3 months later were positive for the whole product, thereby confirming our diagnosis. DISCUSSION: AGEP is drug-induced in more than 90% of cases, mostly after antibiotics, especially beta-lactams and macrolides. Algipan is a topical treatment containing mephenesin used for its analgesic and anti-inflammatory properties in adult muscular pain. No severe skin drug reactions due to this drug have been reported to date. Cases of AGEP induced by topical agents are rarely reported and our case is the first involving mephenesin. Our study suggests that topical mephenesin should be noted as a drug that may cause AGEP.

[Botulinum toxin injection techniques in the lower third and middle of the face, the neck and the décolleté: the "Nefertiti lift"]. / Les techniques d'injection de la toxine botulique dans le tiers inférieur et moyen du visage, le cou et le décolleté. Le "Néfertiti lift".

Although correction of the dynamic wrinkles of the upper part of the face is the major indication for botulinum toxin, there are also many possibilities for the middle and lower thirds of the face and neck. However, these injections are more delicate and require an experienced operator who has excellent knowledge of the muscles of these regions, their functions, the antagonist actions exercised on other muscles, particularly in terms of the complex equilibrium of the mouth. An excessive dose, an inappropriate injection point, or a centering mistake can all easily be responsible for undesirable side effects. However, the results obtained, often with lower doses than in the superior part of the face, can be highly satisfactory, notably in erasing bunny lines, improvement of marionette lines, peau d'orange chin, attenuation of peribuccal lines, melomental folds, correction of a gummy smile, and facial asymmetries. In the neck it is possible to reduce platysmal bands, horizontal lines, and diagonal lines of the neck and décolleté. The face contours can also be improved by the Nefertiti lift. In the mid and lower regions of the face, botulinum toxin is often a complement to other esthetic techniques, particularly filling procedures.

[What's new in aesthetic dermatology: filler and laser treatments]. / Quoi de neuf en dermatologie esthétique : comblement et lasers.

In esthetic dermatology, filling and laser treatments are two essential techniques. Several recent studies on calcium hydroxyapatite in filling treatments and facial volumetry, in esthetics, but also in HIV patients, have been published. It was also tested in accentuated melomental folds where it is superior to hyaluronic acid. In aging of the skin of the dorsal aspect of the hands, hyaluronic acid provides slightly better results than collagen. Filler rhinoplasty can correct minor deformations of the nose. Lipofilling is advantageous for linear scleroderma of the face, at least in the forehead region, and adipocyte stem cells may be a future solution for facial aging or lipoatrophy. The risk of local and/or general sarcoid reactions related to interferon in patients having undergone filling injections has been reported. In the field of laser treatment, fractionated photothermolysis has motivated much more research and seem particularly valuable in treating acne scars, aging of the dorsal aspect of the hands, and, more anecdotally, in colloid milium and pearly penile papules. Laser is also useful in preventing surgical scars where a mini-diode can also be used. For axillary hyperhidrosis, subdermic Nd-YAG laser competes with botulinum toxin, with longer-lasting results. Solutions are appearing for treatment of red or white striae cutis distensae. Intense pulsed light is the reference technique for poikiloderma of Civatte, and seems effective, with new devices, for melasma. However, inappropriately used by nonphysicians, IPL can cause serious ocular accidents; one case of uveitis has been reported.

[Different botulinum toxins and their specifications]. / Les différentes toxines botuliques et leurs spécificités.

Botulinum neurotoxin A was the first developed for therapeutic and then esthetic uses, Botox first and then Dysport. These two products differ on a few points, explaining their nonequivalence of units: American and British tests of the mouse LD50 units based on solutions that were not identical and 500microg vs 150microg serum albumin dose in the excipient. The neurotoxin- accessory protein complexes were also different: 900 kDa homogeneous for Botox, 500 kDa heterogeneous for Dysport, giving greater diffusion for Dysport, but this is under debate and could result from an excessive conversion ratio. Clinical comparative studies, often with weak methodology, have defined an ideal ratio between these two products, guaranteeing efficacy, but without an overly pronounced diffusion. In the first publications for neurological and ophthalmological indications, the conversion ratio between Dysport and Botox was high, 4:1, and sometimes higher. However, today, particularly for cosmetic indications, the trend is toward a much lower ratio, 2.5:1, or perhaps less for dyshidrosis. This lower ratio has an economic incidence: Dysport is less expensive and therefore more competitive. The price of Dysport's cosmetic product, Azzalure, compared to the price of Vistabel, which is Botox's cosmetic presentation, has not yet been defined in France. The other A toxins, Xeomin, and the Asian toxins, MyoBloc (botulinum toxin type B), tested compared to Botox, have a slightly lower efficacy.

The advantage of establishing homogeneous patient groups: is it worth isolating 'juvenile acne of the face'?

BACKGROUND: Acne is a highly heterogeneous disorder with respect to its regional involvement, demographics, lesion types and response to treatment. Homogeneous patient groups must therefore be created before measuring the severity of acne and interpreting the results of therapeutic trials. The individualization of 'juvenile acne of the face' is a first step in this direction. METHODS: Based on textbooks, major reviews of acne and a 'Medline' literature search, we identified four key points to delineate sub groups of acne patients. RESULT: 'Juvenile acne of the face' is defined by four main clinical criteria: (1) age (from puberty to age 25 years), (2) site (face), (3) lesion type (polymorphous), (4) absence of a causal factor. Other subgroups of 'true' acne are listed with their distinctive characteristics. Non-acne follicular diseases (i.e. without sebum retention) are listed. DISCUSSION: We chose 'juvenile acne of the face' to define the first homogeneous group of patients because it is the most frequent form of acne and the target of most acne drugs. It has a sufficiently uniform prognosis to devise a functional and reproducible severity rating scale with the aim of facilitating the evaluation and comparison of therapeutic methods. CONCLUSION: The next step in our work will be to elaborate severity scales which are dedicated to a single type of acne.

A tool to evaluate rapidly the quality of clinical trials on topical acne treatment.

Practicing dermatologists rarely evaluate therapeutic trials. This study was designed to build a simple evaluation tool, use it to evaluate the quality of published trials and thereby consider their applicability. Reports on 146 therapeutic trials, published from 1969 to 2004, were selected. A 50-item list was used for an initial assessment. After comparison with existing grids, a shortened nine-item list was established and used for this analysis. The results were analyzed item by item (logistic regression) and globally (principal component analysis). An index was then established and validated using Cronbach's coefficient alpha. The overall quality of trials was poor: 9% to 73% positive response range. This rate increased after 1990 for six items. Two factors explained almost 60% of the total variance: factor 1 summing six items concerning the formal content of the articles and factor 2 its underlying basis. Using the sum of these six variables, Cronbach's coefficient alpha reached 0.716; their mean sum improved from 1969 to 1970-2001-2005. The significantly improved quality of trials, based on the mean sum over time, supports well-founded basis of this tool. Regarding the application of evidence-based medicine in clinical practice, this tool is user friendly and should facilitate the updating of our knowledge.

[Skin aging: clinicopathological features and mechanisms]. / Vieillissement cutané : Aspects cliniques, histologiques et physiopathologiques.

Skin aging various considerably between individuals and depends on intrinsic factors such as age, oestrogen deficiency during menopause, and on extrinsic factors such as exposure to UV light and tobacco addiction. The clinical and histological characteristics of these different types of aging are described as well as the principle highly complex mechanisms that are involved. Treatment for skin aging has become the main reason why patients consult in cosmetic dermatology. For this reason, dermatologist should know how to analyse this condition and offer suitable therapeutic care that takes into account the aging of the subcutaneous tissue.

[Ablative and fractional lasers]. / Lasers ablatifs et lasers fractionnels.

The use of pulsed or scanning Carbon Dioxide, and pulsed Erbium-YAG lasers allows the programmable and reproducible photocoagulation of thin layers of the epidermis and superficial dermis. Thermal damage depends on the type of laser and is greater with CO(2) lasers. The degree of neocollagenesis is proportional to the thermal damage and is better with CO(2) lasers. Their main indication is the correction of photoaged facial skin but they can also be used for corrective dermatology, e.g. for scars and genodermatosis. Results are highly satisfactory but the technique is invasive and the patient experiences a social hindrance of around two weeks. The fractional techniques such as Fraxel are used to treat non-adjacent microzones without ablation of the epidermis. Around 25 p. 100 of the affected region is treated per session without ablation of the epidermis. Each fraction is only mini-invasive and is performed under local anesthesia. Social hindrance is minimal. Nonetheless, the results are inferior to those obtained with ablative lasers, especially regarding deep wrinkles. The treatment is costly and four sessions are usually required to treat the whole affected area. Others regions of the face may also be treated. Encouraging results have been obtained with mélasma.

[Legal guidelines in aesthetic dermatology]. / Le cadre légal en dermatologie esthétique.

In cosmetic dermatology where treatment is not subject to a therapeutic need, the legal framework must be closely respected. For example, it is essential not to undertake procedures that go beyond the scope of one's training, an insurance policy is mandatory, and the patient's fully informed consent must be obtained. Information must be clear, objective and understandable to the patient, so discussion with him/her is of paramount importance. Fact sheets are useful but are not to be used instead of discussion. The patient should receive an estimate and be given two weeks t think things over before giving his/her informed consent. In the event of the patient filing a complaint, it is up to the clinician to prove that the patient received adequate information, hence the importance of keeping all documentary evidence such as an updated medical file and copies of all correspondence. The estimate must be signed by the patient but not the fact sheets, contrary to what has come to be common practice in some institutions. Insurance companies need a document signed by the patient. This may be a pre-printed form stating that the patient has been fully informed by the clinician and has given his//her informed consent to the planned procedure.

[Cyclosporine-induced follicular eruption]. / Toxidermie folliculaire à la ciclosporine.

BACKGROUND: Cyclosporine is one of the immunosuppressant agents most widely used in the prevention and treatment of organ transplant rejection and also in autoimmune diseases. Many cutaneous side effects have been described with oral cyclosporine, mainly in transplant recipients, for example, hypertrichosis, gingival hyperplasia and viral skin infections. Here, we report an unusual follicular eruption induced by this drug. PATIENTS AND METHODS: A 22-year-old man presenting cystic fibrosis received a double-lung graft in January 2005. Six weeks later, he developed a subacute eruption of follicular papules, not highly pruritic, located mainly on the trunk, the extensor surfaces of the limbs and the face. Diagnosis of cyclosporine-induced follicular eruption was adopted on the basis of the histological and microbiological findings. Complete regression was obtained after switching to tacrolimus. DISCUSSION: Three similar cases were previously reported characterized by typical follicular changes different from those observed in hypertrichosis or pilar keratosis. This rare cutaneous side effect may be explained by the direct action of cyclosporine on the pilosebaceous unit: this drug is known to extend the anagen phase of the follicular cycle and to induce toxic follicular dystrophy at higher tissue concentrations. This particular toxicity is usually seen after many months of treatment. In our patient, the time to onset was shorter, probably due to occasionally excessive plasma concentrations.