Assessing Implicit Bias in Dermatology.

BACKGROUND: Patients with skin of color (SOC), defined as Fitzpatrick skin types IV to VI, and of varying ethnicities are under-represented in dermatology. This includes practitioners, trainees, dermatologic teaching materials, and clinical studies.  Methods: Online survey study to assess dermatologists’ perceptions that could impact patient care. Participants were screened for providers that spent ≥80% of their time in direct patient care; managed ≥100 unique patients per month; and had ≥20% aesthetic patients. RESULTS: A total of 220 dermatologists participated; 50 with SOC, 152 non-SOC, and 18 other. SOC dermatologists had a more diverse patient population by racial/ethnic background, but there was no difference in proportion of patients by Fitzpatrick skin phototype categories. While race/ethnicity is not considered a primary factor in clinical decision making, Fitzpatrick skin type is for many dermatologists. Most dermatologists agree that more diversity in medical training for dermatologic conditions would be beneficial. Dermatologists report that adding before and after photos of different skin types in educational materials and increasing training on cultural competency are likely to be the most effective strategies for improvement. CONCLUSIONS: Although racial/ethnic diversity shows differences based on location of practice and the race of dermatologists, diversity of skin type based on Fitzpatrick scale is virtually identical across practices, illustrating the challenge of categorizing patients by this scale alone. Beer J, Downie J, Noguiera A, et al. Assessing implicit bias in dermatology. J Drugs Dermatol. 2023;22(7):635-640. doi:10.36849/JDD.7435.

Removal of p-cresol using wash waters from lipopeptide production.

This work shows the efficiency of wash waters from lipopeptide production as a remediation strategy to treat urban water samples contaminated with p-cresol. The harvesting step in surfactin production involved a centrifugation step, generating a major soluble fraction and a fraction that is adsorbed to the biomass. The adsorbed fraction was recovered by washing steps. These wash waters containing lipopeptides (mostly surfactins), were successfully used to adsorb and solubilize p-cresol. The method of decontamination applied to an artificially contaminated natural water was monitored using a biosensor based on laccase/magnetic nanoparticles. Given the amount of surfactin within the wash water, the removal of p-cresol from artificially contaminated water was approximately 46.0%. This result confirms the successful and sustainable application of surfactin-rich wash waters to remove p-cresol from artificially contaminated natural water. The adsorption mechanism is potentially based on a multi-layer adsorption process, considering Langmuir and Freundlich adsorption isotherms.

Postmarket Safety Surveillance of Delayed Complications for Recent FDA-Approved Hyaluronic Acid Dermal Fillers.

OBJECTIVE: To review postmarketing data for delayed (≥14 days post-treatment) adverse events (AEs) of interest (inflammatory and noninflammatory nodules, hypersensitivity, granulomas) for newer hyaluronic acid (HA) fillers FDA-approved within the last 5 years (2016-2020). METHODS: Reports from the Manufacturer and User Facility Device Experience (MAUDE) database were extracted for HAREF, HADEF, HAKYS, HAVER, HAVLR, HAVOB, HARH2, HARH3, and HARH4 from January 2016 to January 2021. Keywords from event narratives were used to identify and categorize AEs and then verified through inclusion/exclusion criteria. Percentages are based on the total combined events of interest to provide an overall perspective of the events reported during the search period. RESULTS: Of 585 MAUDE reports, there were 195 (33.3%) delayed AEs of interest. Of those, 71.8% were nodules (42.1% inflammatory and 29.7% noninflammatory), 21.5% hypersensitivity, and 6.7% granulomas. The combined total events of interest, ordered by frequency reported, were HAVLR (74.4%), HAVOB (12.3%), HADEF (5.1%), HARH4 (3.6%), HAREF (2.6%), and HARH2 (2.1%), with no reports for HARH3, HAVER, and HAKYS. CONCLUSION: Although delayed nodules and inflammatory events are rare, reports for these events were extracted from the MAUDE database from 2016 to 2020 for HAVLR, HAVOB, HADEF, HARH4, HAREF, and HARH2 (most to least frequent).

Residual biomass from surfactin production is a source of arginase and adsorbed surfactin that is useful for environmental remediation.

Lipopeptides are important secondary metabolites produced by microbes. They find applications in environmental decontamination and in the chemical, pharmaceutical and food industries. However, their production is expensive. In the present work we propose three strategies to lower the production costs of surfactin. First, the coproduction of surfactin and arginase in a single growth. Second, extract the fraction of surfactin that adsorbs to the biomass and is removed from the growth medium through centrifugation. Third, use microbial biomass for the remediation of organic and inorganic contaminants. The coproduction of surfactin and arginase was evaluated by factorial design experiments using the LB medium supplemented with arginine. The best conditions for surfactin production were 22 h of growth at 37 °C using LB supplemented with arginine 7.3 g/L. Almost similar conditions were found to produce highest levels of arginase, 24 h and 6.45 g/L arginine. Decontamination of phenol and copper from artificial samples was attained by treatment with residues from lipopeptide production. Thus, cell suspensions and wash-waters used to extract surfactin from the biomass. Cell suspensions were used to successfully remove hydroquinone. Cell suspensions and wash-waters containing surfactin were successfully used to recover copper from solution. Specific monitoring methods were used for phenol and metal solutions, respectively a biosensor based on tyrosinase and either atomic absorption flame ionization spectrometry or absorbance coupled to the Arduino™ platform. Therefore, we report three alternative strategies to lower the production costs in lipopeptide production, which include the effective recovery of copper and phenol from contaminated waters using residues from surfactin production. Sustainable and profitable production of surfactin can be achieved by a coproduction strategy of lipopeptides and enzymes. Lipopeptides are collected in the supernatant and enzymes in the biomass. In addition, lipopeptides that coprecipitate with biomass can be recovered by washing. Lipopeptide wash-waters find applications in remediation and cells can also be used for environmental decontamination.

Lay rater evaluation of naturalness and first impression following treatment of lower face wrinkles with hyaluronic acid fillers.

BACKGROUND: Hyaluronic acid (HA) dermal fillers formulated with XpresHAn TechnologyTM were subjectively assessed by investigators and subjects. AIMS: To test whether treatment with HA dermal fillers (HARR and HARD ) deemed natural by injectors and subjects are considered natural by the public and receive positive first impressions. METHODS: Videos of open-smile expressions of subjects at baseline to Day 42 were assessed by "lay raters" (n = 3004) who indicated agreement with "Face looks natural" and first impressions using Likert-type scales. RESULTS: Naturalness of facial appearance was noninferior at Day 42 compared with baseline. Assessments of first impression demonstrated statistically significant changes from baseline in overall first impression, social skills, dating success, attractiveness, and athletic success. Rater gender and age did not affect scores. Subgroup analysis found three groups had significant positive changes: those aged ≤ 55 years, subjects with natural outcome, and those that received more than 4 mL of filler. Subjects without a natural outcome had a significant negative change. CONCLUSIONS: Treatment with HA facial fillers, HARR and HARD , produces outcomes deemed natural by injectors, subjects, and the public. While subjective, this study demonstrates that clinicians should aim for a "natural outcome" that receives optimal first impressions from the public.

An Objective, Quantitative Assessment of Flexible Hyaluronic Acid Fillers in Lip and Perioral Enhancement.

BACKGROUND: HARK is an FDA-approved flexible filler designed for lips. OBJECTIVE: To quantitatively evaluate subject outcomes by measuring the change in lip texture, color (redness), lip fullness, and lip and perioral surface stretch (dynamic strain) after treatment. METHODS AND MATERIALS: In this 8-week open-label, Phase IV multicenter study, subjects were treated with HARK in the lips and HARR and/or HARD in perioral wrinkles and folds as add-on treatment. Assessments included 2D photographic analyses of lip texture and color, and 3D photographic assessments of lip enhancement and dynamic strain. RESULTS: HARK significantly improved lip texture (p ≤ .002), lip redness (p < .001), and added fullness to the lips (lip enhancement measurements; p < .001), at Week 8 after treatment. In addition, lower lip wrinkles were significantly reduced (p = .007) and there was a reduction in upper lip wrinkles (not statistically significant). Surface stretch (dynamic strain) in the lip and perioral region was significantly increased after treatment (p < .001). CONCLUSION: This analysis provides an objective measure of the beneficial effects of flexible hyaluronic acid fillers in lip augmentation and perioral enhancement and demonstrates a significantly improved lip texture, red color, and fullness. A significant increase in surface stretch (dynamic strain) is indicative of tissue expansion and improvement in lip smoothness.

An Objective, Quantitative, Dynamic Assessment of Hyaluronic Acid Fillers That Adapt to Facial Movement.

BACKGROUND: Objective dynamic assessments are central to the evaluation of facial rejuvenation treatments. This study used three-dimensional digital stereophotogrammetry to generate a quantitative dynamic assessment of facial strain and hyaluronic acid filler efficacy. METHODS: Thirty women (aged 41 to 65 years) with moderate to severe bilateral nasolabial folds and marionette lines received Restylane Refyne, Restylane Defyne, or both, and were compared to a "younger" untreated group (n = 20; aged 25 to 35 years). Three-dimensional videos were collected at baseline and at day 42. Dynamic strain was analyzed at the marionette lines and nasolabial folds as subjects went from a neutral position through a series of facial expressions. RESULTS: Baseline nasolabial folds and marionette lines showed statistically significant (p ≤ 0.05) differences in the level of stretch between younger and older untreated subjects, with higher stretch profiles observed in the older cohort. In the older cohort, filler treatment reduced peak strain (stretch) in the nasolabial folds and marionette lines compared with baseline across all tested expressions, resembling the youthful strain profile of the younger untreated control group. Treatment was well tolerated. CONCLUSIONS: Quantitative dynamic strain analysis is an innovative method for evaluating the dynamic face following dermal fillers and provides objective evidence that such treatment results in stretch levels resembling a younger phenotype in areas prone to the effects of facial aging. The strain reduction following filler treatment objectively conveys a dermal tightening effect, likely secondary to the volumization of treated areas. Additional studies will refine the technology and associated procedures to optimize quantitative dynamic strain analysis for treatment planning and patient outcome optimization. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Dynamics of hyaluronic acid fillers formulated to maintain natural facial expression.

BACKGROUND: Subjects seeking facial rejuvenation want the results to appear natural. Currently, however, there is no consensus definition of, or assessment scale for, "naturalness." AIMS: This open-label pilot study explored evaluation techniques and criteria to assess naturalness of facial movement and expression following optimal bilateral correction of moderate-to-severe nasolabial folds and marionette lines with soft-tissue hyaluronic acid fillers formulated with XpresHAn Technology™. METHODS: Primary efficacy was investigator assessed naturalness of dynamic expressions using baseline and Day 42 posttreatment 2D video. Other evaluations included investigator assessed naturalness using static images, wrinkle severity, investigator and subject Global Aesthetic Improvement Scale assessments, and subject satisfaction. RESULTS: Thirty Caucasian females (41-65 years) received either Restylane® Refyne, Restylane® Defyne or both. Naturalness of dynamic expressions was at least maintained in all subjects. Naturalness of static expressions was not negatively affected in most subjects (96.7%). For dynamic expressions, 83.3% of subjects showed enhanced attractiveness, younger appearance and maintained naturalness. CONCLUSIONS: Overall, nasolabial folds and marionette lines improved significantly based on severity and Global Aesthetic Improvement Scale scores, with high subject satisfaction and favorable safety profile. Based on subject satisfaction and investigator assessments, using highly flexible hyaluronic acid dermal fillers did not compromise naturalness of lower facial expressions while achieving the desired improvements in attractiveness and youthfulness. The preliminary results obtained in this pilot study suggest that dynamic and static assessments of facial animation may aid the evaluation of natural outcomes in facial rejuvenation procedures.

Clinical Assessment of 2 Licensed AbobotulinumtoxinA Injection Volumes for the Treatment of Glabellar Lines.

BACKGROUND: Two licensed reconstitution volumes may be used to achieve the recommended abobotulinumtoxinA (ABO) dose for glabellar line correction. OBJECTIVE: Comparison of efficacy, safety, and subject satisfaction concerning treatment of moderate to severe glabellar lines with 2 different ABO reconstitution volumes. MATERIALS AND METHODS: Phase IV, prospective, randomized, multicenter, subject- and evaluator-blinded study: 60 subjects received 1 ABO (50 units) treatment, administered as a 1.5- or 2.5-mL reconstitution. Primary objective was Day 30 improvements (≥1-point) in glabellar line severity. Onset of effect, duration, subject satisfaction, and treatment-related adverse events (AEs) were assessed. RESULTS: At Day 30, 90.0% and 86.7% of subjects achieved ≥1-point improvements with 1.5- and 2.5-mL reconstitutions, respectively. Median time to onset of effect was 48 hours after treatment. At 24 hours, 26.7% achieved ≥1-point improvements with the 2.5-mL reconstitution versus 6.7% with the 1.5-mL reconstitution. Maximum response was at Day 14, and >40% maintained efficacy through Day 120 in each group. High subject satisfaction was sustained throughout observation. Most AEs were mild. No serious AEs were reported. CONCLUSION: Both ABO reconstitutions were well tolerated and effective in correcting glabellar lines with no significant differences concerning efficacy or duration of effect. No serious AEs were reported.

Comparison of Hyaluronic Acid Gel With (HARDL) and Without Lidocaine (HAJUP) in the Treatment of Moderate-To-Severe Nasolabial Folds: A Randomized, Evaluator-Blinded Study.

BACKGROUND: Injectable fillers, such as those containing hyaluronic acid (HA), are increasingly used to smooth age-related facial creases and wrinkles. OBJECTIVE: To compare efficacy and safety of a HA gel with lidocaine formulated by XpresHAn Technology (HARDL) with a HA gel without lidocaine produced by Hylacross technology (HAJUP) in the treatment of moderate-to-severe nasolabial folds. MATERIALS AND METHODS: Subjects (n = 162) received initial and touch-up injections with HARDL and HAJUP on either side of the face. Investigator- and subject-assessed wrinkle severity was measured up to 48 weeks after final injection. RESULTS: Mean (SD) Wrinkle Severity Rating Scale was improved by 1.1 (0.75) and 1.1 (0.68) with HARDL and HAJUP, respectively, at 24 weeks; improvements were sustained up to Week 48 with both treatments. Noninferiority of HARDL was demonstrated (mean difference -0.09 [95% confidence interval: -0.18 to -0.01], p = .032) at 24 weeks. Adverse events were reported in 43% subjects, 12% were treatment related, with a similar distribution for both treatments. CONCLUSION: Effectiveness and safety profiles of HARDL and HAJUP were comparable.

A Novel and More Aesthetic Injection Pattern for Malar Cheek Volume Restoration.

The loss of superior midface contour and projection can be corrected with the use of injectable hyaluronic acid (HA) dermal fillers, however, the most frequently used injection pattern employs a technique which was originally designed for malar implant surgery. Here we describe a novel injection pattern for restoring facial contours with a HA dermal filler inspired by traditional make-up artistry, which includes greater superolateral positioning of injection sites. Importantly, this technique helps injectors avoid creating an excess of volume in the anterior portion of the malar complex. Contributing authors/injectors, who now use this technique exclusively, have found that it has so far provided optimal aesthetic results for hundreds of patients with no observables complications. The malar cheek contributes much to the aesthetic curvature of the face and deserves a thoughtful update for injectable HA, as the traditional technique has never actually been aligned with its medium. In the experience of the contributing authors, this technique helps achieve a greater aesthetic outcome in the correction of midface contour deficiencies and has consistently resulted in high patient satisfaction. Level of Evidence IV 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 .

Hyaluronic Acid Gel With (HARRL) and Without Lidocaine (HAJU) for the Treatment of Moderate-to-Severe Nasolabial Folds: A Randomized, Evaluator-Blinded, Phase III Study.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are frequently used to correct or smooth facial wrinkles and folds such as nasolabial folds. OBJECTIVE: To compare the efficacy and safety of 2 HA gels, formulated by 2 different manufacturing processes: XpresHAn Technology (HARRL [with lidocaine]) and Hylacross technology (HAJU-a comparator product without lidocaine). PATIENTS AND METHODS: One hundred seventy subjects with bilateral nasolabial folds rated as moderate or severe, according to the Wrinkle Severity Rating Scale (WSRS), received injections of HARRL in the nasolabial folds on one side of the face and HAJU on the other side. Investigator- and subject-assessed wrinkle severity was measured up to 48 weeks after final injection. RESULTS: HARRL exhibited a similar safety and efficacy profile compared with HAJU. Noninferiority of HARRL was demonstrated at 24 weeks (WSRS mean change from baseline mean difference -0.1 [95% confidence interval: -0.15, 0.01], p = .090). Incidence of adverse events was 40% for both treatments. CONCLUSION: HARRL exhibited a similar safety and efficacy profile compared with HAJU.

Hyaluronic acid gel filler for nipple enhancement following breast reconstruction.

The loss of the 3-dimensional contour of the nipple-areola complex (NAC) following surgical breast reconstruction is a technical challenge for the physician and a psychological burden for many breast cancer patients. The use of injectable dermal fillers to enhance nipple projection is a simple noninvasive procedure with immediate and adjustable volume results that positively impact patient satisfaction. The utility and safety of injectable hyaluronic acid (HA) gel make it an ideal filler for restoring the natural feel and contour to the delicate structure of the NAC and in some cases may represent a simple solution following breast reconstruction.

Minimal recovery time needed to return to social engagement following nasolabial fold correction with hyaluronic acid fillers produced with XpresHAn technology.

INTRODUCTION: The appeal of hyaluronic acid fillers for facial soft tissue augmentation is attributable to both an immediate aesthetic effect and relatively short recovery time. Although recovery time is an important posttreatment variable, as it impacts comfort with appearance and perceived treatment benefit, it is not routinely evaluated. Natural-looking aesthetic outcomes are also a primary concern for many patients. MATERIALS AND METHODS: A single-center, noncomparative study evaluated the time (in hours) until subjects return to social engagement (RtSE) following correction of moderate and severe nasolabial folds (NLFs) with RR (Restylane® Refyne)® and RD (Restylane Defyne), respectively. Twenty subjects (aged 35-57 years) who received bilateral NLF correction documented their RtSE and injection-related events posttreatment. Treatment efficacy was evaluated by improvements in Wrinkle Severity Rating Scale (WSRS) and subject satisfaction questionnaire at days 14 and 30, and by Global Aesthetic Improvement Scale (GAIS) at day 30. Safety was evaluated by injection-related events and treatment-emergent adverse events. RESULTS: Fifty percent of subjects reported RtSE within 2 hours posttreatment. WSRS for the RR group improved significantly from baseline at day 14 (-1.45±0.42) and day 30 (-1.68±0.46) (P<0.001), respectively. WSRS for the RD group improved significantly from baseline at day 14 (-2.22±0.44) and day 30 (-2.50±0.50) (P<0.004), respectively. All GAIS improvements were clinically significant at day 30. The majority of injection-related events were mild or moderate. Two subjects experienced 3 related treatment-emergent adverse events; 1 RR subject experienced severe bruising, and 1 RD subject experienced severe erythema and mild telangiectasia. Subject satisfaction was high regarding aesthetic outcomes and natural-looking results. CONCLUSION: Optimal correction of moderate NLFs with RR and severe NLFs with RD involved minimal time to RtSE for most subjects. Treatments that significantly improved WSRS and GAIS, were generally well-tolerated, and provided natural-looking aesthetic outcomes.

Cosmetic Use of AbobotulinumtoxinA in Men: Considerations Regarding Anatomical Differences and Product Characteristics.

The proportion of men seeking facial rejuvenation with botulinum neurotoxin type A (BoNTA) products is increasing. The number of male patients treated in the 5-year period between 2009 and 2014 grew by 25%. There is little clinical data supporting gender-specific efficacy with regard to dosing and injection placement in men. To nurture the confidence associated with treatment of male patients, clinicians are in need of more informational materials to develop their evaluation and treatment strategies. Three BoNTA products are currently available in the United States (US) for treatment of the upper face. The varying potency of the different BoNTA formulations is reflected by disparate dose-response characteristics, meaning they are not interchangeable for injection purposes. Clinicians who are familiar with the characteristics of all the BoNTA options will be equipped with the necessary tools to provide their male patients with a desired outcome.
Among the product options available in the US, Dysport® (abobotulinumtoxinA) (Galderma Laboratories, L.P., Fort Worth, Texas) is unique in that its recommendations for reconstitution provide the clinician with 2 different final product concentrations. The flexibility provided by a variable dose may be a valuable tool for tailoring treatments to male patient-specific needs, which may include a more conservative outcome, maintaining a certain degree of muscle activity and expressivity. Achieving a conservative outcome may be the key to a positive experience for the male patient.

J Drugs Dermatol. 2016;15(9):1056-1062.

Lip Injection Techniques Using Small-Particle Hyaluronic Acid Dermal Filler.

The shape and fullness of the lips have a significant role in facial aesthetics and outward appearance. The corrective needs of a patient can range from a subtle enhancement to a complete recontouring including correction of perioral rhytides. A comprehensive understanding of the lower face anatomical features and injection site techniques are foundational information for injectors. Likewise, the choice of filler material contributes to the success of the injection techniques used, and facilitates a safe, effective, and natural appearing outcome. The small-particle HA 20 mg/mL with lidocaine 0.3% (SP-HAL, Restylane® Silk; Galderma Laboratories, Fort Worth, Texas) is indicated for submucosal implantation for lip augmentation and dermal implantation for correction of perioral rhytides. Due to its rheological properties and smaller particle size, SP-HAL is a well-suited filler for the enhancement and correction of lip shape and volume, as well as for the correction of very fine perioral rhytides. This work is a combined overview of techniques found in the current literature and recommendations provided by contributing authors.

J Drugs Dermatol. 2016;15(9):1076-1082.

Effectiveness and Safety of Large Gel Particle Hyaluronic Acid With Lidocaine for Correction of Midface Volume Deficit or Contour Deficiency.

BACKGROUND: Aging effects, such as facial flatness, increased tissue laxity, and soft tissue descent and deflation, contribute to midface deficiency. OBJECTIVE: To evaluate whether large gel particle hyaluronic acid with lidocaine (LGP-HAL) is more effective in the treatment of midface deficiencies than no treatment. MATERIALS AND METHODS: Subjects with mild to substantial loss of midface fullness were randomized 3:1 to LGP-HAL (Restylane Lyft; Galderma Laboratories, L.P., Fort Worth, TX) or no treatment. Treatment success was defined as at least 1-grade improvement in Medicis Midface Volume Scale (MMVS) on each side of the face at 8 weeks as assessed by a blinded evaluator. Secondary efficacy end points included MMVS score, global aesthetic improvement, and subject satisfaction. RESULTS: Significantly greater percent of subjects achieved treatment success in the LGP-HAL group compared to no treatment at all time points through Month 12 (p < .001). One year after initial treatment, 85% of subjects still had a global aesthetic improvement assessed by the treating investigator. Subject satisfaction demonstrated that LGP-HAL improved the aesthetic appearance of the midface. Most reported adverse events (80%) were mild in severity. CONCLUSION: The LGP-HAL treatment is well tolerated and provides significant improvement up to 12 months for the correction of midface deficiencies.

Cidadão humilde lendo as leis

A image, representa uma charge que retrata um cidadão confuso ao consultar livro sobre legislação.