Supervision Unveiled; Navigating the Supervision Landscape in Medical Spas.

BACKGROUND: There is an ongoing increase in the demand for injectable procedures and an increase in the number of medical spas across the United States State regulations significantly vary regarding level of supervision at these medical spas. OBJECTIVE: The aim of this study was to determine who performs cosmetic procedures, provides medical supervision, and who is being informed of complications. METHODS: Descriptive study based on a standardized telephone interview performed by a prospective patient for injectable treatments performed at medical Spas in Las Vegas. Data were then extracted and analyzed. RESULTS: Of 63 medical spas reviewed, most of the injectable treatments (73%) were performed by nonphysicians. An onsite physician who supervised or personally performed the cosmetic procedures was present in only 38.1% of the spas surveyed. Only 46% of surveyed medical spas notify a medical director/supervising physician in the event of a complication and only 39.7% of surveyed spas had a number to call after regular business hours. CONCLUSION: The majority of treatments are performed by nonphysicians in the spas surveyed. Physician supervisors are not on site in most of the spas and about half of spas do not inform the medical director in the event of a complication.

Comparing the Safety and Effectiveness of Microfocused Ultrasound: Standard vs Targeted Tissue Protocol in Lifting and Tightening the Lower Face and Upper Neck.

BACKGROUND: Micro-focused ultrasound with visualization (MFU-V) delivers energy to specific soft tissue layers beneath the epidermis with the ability to lift and tighten the lower face and neck.  Objective: To determine the efficacy of microfocused ultrasound with visualization (MFU-V) using a standard treatment line protocol versus a customized treatment line protocol based on the patient's unique anatomy targeting the superficial muscular aponeurotic system and fibrous septae for lifting and tightening of the lower face and neck. METHODS: This was a single-center, prospective, randomized, investigator-blinded clinical trial. 51 subjects were randomized to receive a single treatment of MFU-V targeting the lower face and neck using either a standard or custom treatment protocol.   Results: Subjects in both standard and custom treatment groups noted a greater than one-point improvement in jawline laxity. Three-dimensional photography measurements also demonstrated lifting of the lower face and neck in both treatment groups. CONCLUSION: Custom and standard treatment MFU-V protocols produce a safe and effective treatment for tightening and lifting the lower face and neck. Custom treatment protocols aid in maximizing results for patients with variations in the anatomy of the lower face and neck.  J Drugs Dermatol. 2024;23(4):7647.     doi:10.36849/JDD.7647.

Collagenase Clostridium Histolyticum-aaes Injections for Volumetric Change of Cellulite Dimples and Gluteal Contouring.

BACKGROUND: Collagenase clostridium histolyticum-aaes (CCH) is approved for the treatment of moderate-to-severe cellulite. OBJECTIVE: This is a retrospective image review of subjects previously enrolled in Cohort 2 of the EN3835-305 trial to determine the effects of CCH on volumetric changes of cellulite dimples and overall gluteal contouring. METHODS: In this retrospective analysis, photographs from Day 90 and Day 180 were superimposed on baseline images and the volumetric change of each treated cellulite dimple was quantified. Side-by-side photographs of the buttocks were also evaluated for change in gluteal contour using the Physician Global Aesthetic Improvement Scale (PGAIS). RESULTS: Fifty-eight female subjects and 403 cellulite dimples were evaluated. Three-dimensional imaging analysis revealed a significant improvement in total negative dimple volume at both Day 90 and Day 180 of 27% and 26%, respectively ( p < .001 and p = .002, respectively). At Day 90, the overall gluteal contour, as signified by the mean PGAIS among the 3 blinded dermatologists, was rated as +1 (improved) in 27% ( n = 17) of the subjects. At Day 180, the mean PGAIS was +1 (improved) or +2 (very much improved) in 39% ( n = 26) of the subjects. CONCLUSION: CHH is an effective tool for treating cellulite dimples and improving gluteal contour.

A Randomized, Single-Center, Double-Blinded, Split-Body Clinical Trial of Poly- l -Lactic Acid for the Treatment of Cellulite of the Buttocks and Thighs.

BACKGROUND: More than 90% of women report concerns of cellulite on their skin. Poly- l lactic acid (PLLA-SCA) is a biocompatible, semipermanent, synthetic filler that induces neocollagenesis. OBJECTIVE: To investigate the safety and efficacy of PLLA-SCA for the treatment of cellulite of the buttock and thigh regions. METHODS: This was a prospective, single-center, double-blinded, split-body, clinical trial of 20 women with slight to moderate skin laxity of the buttocks and/or thighs contributing to mild-to-moderate cellulite. Each subject's buttocks and thighs were randomized to receive injections with up to 2 vials of PLLA-SCA or the equivalent volume of bacteriostatic water per treatment area. Subjects received at total of 3 treatments 4 weeks apart and were followed for 330 days. RESULTS: Treatment of the buttocks with PLLA-SCA resulted in significant reduction of depression depth, improvement in the morphological appearance of the skin, improvement in the grade of skin laxity, and overall improvement in cellulite appearance. Treated thighs showed reduction in the depth and number of depressions and an improvement in overall cellulite appearance. No significant procedure side effects were found. CONCLUSION: Poly- l lactic acid offers an effective and safe method for treating cellulite of the buttocks and thighs.

Efficacy and Safety of Intense Pulsed Light and Nonablative Fractional 1440-nm Diode Laser to a Combination of the 2 Modalities for Facial Rejuvenation.

BACKGROUND: The aging process involves laxity, hyperpigmentation, and telangiectasias. It is important to target those elements of aging to be successful at achieving rejuvenation. OBJECTIVE: To determine the efficacy, safety, and patient satisfaction of a combination intense pulsed light (IPL) and 1440-nm diode laser versus either treatment alone. METHODS: Forty subjects were enrolled in this randomized split-face trial: 20 were randomized to Group A (received IPL on one side of the face and IPL followed by the 1440-nm diode laser on the other side) and 20 were randomized to Group B (received 1440-nm diode laser on one side of the face and IPL followed by the 1440-nm diode laser on the other side). RESULTS: Investigators reported a percent improvement of 40% to 50% in all 3 groups at day 120; blinded investigator Global Aesthetic Improvement Scores were better in the combination group-90% compared with 84% and 83% in the IPL and 1440-nm diode laser groups, respectively. Wrinkling scores was significantly improved in the 1440-nm diode and combination groups. Hyperpigmentation and telangiectasias were significantly improved in all 3 groups. Adverse events were self-limited. CONCLUSION: Combination treatment with IPL and 1440-nm diode laser was found to be safe and effective and resulted in higher subject satisfaction.

The Efficacy and Safety of Radiofrequency Microneedling Versus a Nonablative Fractional 1,550-nm Erbium:Glass Laser for the Rejuvenation of the Neck.

BACKGROUND: Radiofrequency microneedling (RFMN) and nonablative fractional 1,550-nm erbium:glass lasers (NAFLs) have been reported to be used with success in neck rejuvenation. There are no head-to-head trials to compare these modalities. OBJECTIVE: The purpose of the study was to compare the efficacy and safety of radiofrequency microneedling and nonablative fractional 1,550-nm erbium:glass lasers for the rejuvenation of the neck. METHODS: This was a single-center, randomized, investigator-blinded clinical trial. A total of 21 subjects were randomized into 2 groups, NAFL and RFMN; subjects received 3 treatments 4 weeks apart and were followed up 12 weeks after last treatment. RESULTS: Subjects in NAFL and RFMN groups showed 42.1% and 8.6% improvement in the Fitzpatrick-Goldman Wrinkling Score, respectively, 41.3% and 16.3% improvement in the elastosis score, respectively. Subjects in the NAFL 1,550-nm erbium:glass group showed significantly better blinded investigator Fitzpatrick-Goldman Wrinkling and Elastosis scores; subjects in the RFMN groups showed a more significant reduction in the Horizontal Neck Wrinkle Severity Score. There was a trend for higher patient satisfaction with the NAFL. CONCLUSION: This study showed that both treatments resulted in significant improvement in wrinkling and elastosis scores; the NAFL treatment was associated with significantly better blinded investigator Fitzpatrick-Goldman Wrinkling and Elastosis scores and better subject satisfaction.

Large Varicose Vein Closure: A Comprehensive Review.

BACKGROUND: Treatment of chronic venous disease and varicose veins has significant psychosocial and economic impact. The great saphenous vein is a common vein to develop incompetence and reflux and, therefore, been the focus of therapy for many years. OBJECTIVE: To review the published medical literature relating to large varicose vein closure and provide a guide for closure techniques' efficacy and safety. METHODS: A comprehensive search of the English language literature was performed up to and including December 2021. All references pertaining to large varicose vein closure were reviewed. RESULTS: There are multiple safe and effective minimally invasive methods to achieve occlusion of incompetent great saphenous vein, the most widely used of which is endovenous thermal ablation. Other nonthermal, tumescent, and nontumescent methods can also be used. CONCLUSION: Proper knowledge of vein anatomy, ultrasound, and vein closure procedures is needed to ensure safe and effective outcomes.

A Prospective, Randomized, Double-Blind, Vehicle-Controlled Study Evaluating the Efficacy, Safety, and Patient Satisfaction of Tretinoin 0.05% Lotion for Chest Rejuvenation.

BACKGROUND: There is increasing interest in non-invasive options for chest rejuvenation with minimal to no downtime. Topical retinoids have long been used to correct photoaging due to their ability to promote epidermal hyperplasia, matrix metalloproteinase inhibition, collagen synthesis, and dispersion of melanin granules. Topical retinoid use is often limited by the ensuing irritation that occurs with initial use and resolves after about one month. Vehicle of delivery is a key factor to consider in order to minimize irritation and increase patient satisfaction. Micronized tretinoin 0.05% suspended in a polymer emulsion of hydrating ingredients (sodium hyaluronate, soluble collagen, and glycerin) is designed to aid in reducing irritation while ensuring uniform drug delivery. OBJECTIVE: The primary objective of our study is to evaluate the safety, efficacy, and patient satisfaction of tretinoin 0.05% lotion for nonprocedural photorejuvenation of the chest. RESULTS: A total of 29 patients completed the trial, average age of 54.42 years (37-66 years old), Fitzpatrick II-IV skin types. Both the active and vehicle groups showed 30-40% improvement at day 180 according to the blinded evaluator mean percent improvement. Investigator global aesthetic improvement scale also trended towards improvement in both groups, with most patients exhibiting "improvement." Both the active and vehicle groups showed a significant change over time according to the nine-point photodamage and wrinkling scale, P<0.001 and P=0.007 (single factor ANOVA), respectively. The Fabi Bolton Wrinkle Scale also demonstrated improvement from screening to day 180; however, there was no statistical significance at any time point. At day 90, the active group had statistically significantly more erythema than the vehicle group (P<0.001), although both groups were only mild. At day 180, erythema decreased in both groups with the active group being similar to the vehicle group, 0.50±0.73 versus 0.09±0.30, respectively. Subjects in both the active and vehicle groups were equally satisfied at day 180, (2.38±1.15 in the active group versus 2.30±1.16 in the treatment group), with most subjects feeling "satisfied" with their results by day 180. This was also reflected in the subject global aesthetic improvement scale with most subjects noting noticeable improvement in the appearance of their chest from day 30 to day 180. CONCLUSION: Tretinoin 0.05% lotion delivered in a proprietary blend of hydrating ingredients offers a safe and efficacious option that has minimal downtime for patients seeking non-procedural photo-rejuvenation of the chest. The proprietary vehicle, containing hyaluronic acid, glycerin, and collagen, was crucial in minimizing irritation and producing at least a one-point improvement according to the 9 point photodamage scale and 30-40% improvement in photodamage as noted by the blinded evaluator percent improvement score in both the vehicle and active groups. J Drugs Dermatol. 2022;21(6):645-652. doi:10.36849/JDD.6658.

Evaluation of an SPF50 Sunscreen Containing Photolyase and Antioxidants for its Anti-Photoaging Properties and Photoprotection.

BACKGROUND: Background: Skin exposure to ultraviolet radiation (UVR) causes DNA damage, which can lead to mutagenesis, carcinogenesis, cellular death, and photoaging. Signs of photoaging include wrinkling, erythema, skin laxity, uneven skin texture, and hyperpigmentation. Photolyase is an exogenous DNA repair enzyme that can restore DNA integrity when applied topically to human skin. Antioxidants also play a key role in reducing UVR-associated molecular damage. OBJECTIVE: To assess the efficacy and safety of a tinted mineral-based sunscreen containing 10.7% zinc oxide (SPF50) with the active ingredients photolyase, antioxidants (Peptide Q10), and peptides in both protecting and repairing signs of photoaging. METHODS: In an open-label, single-center, 12-week study, patients aged 35–55 years and Fitzpatrick skin phototypes II–IV applied the sunscreen daily for 84 days. VISIA photography was performed at baseline as well as 6- and 12-week follow-ups. At each visit, the investigator and subject evaluated clinical photoaging parameters including overall photodamage, fine lines/wrinkles, coarse lines/wrinkles, skin tone evenness, tactile roughness, and radiance. RESULTS: The Investigator Global Aesthetic Improvement Scale (IGAIS) found that 63% of patients showed improvement at week 6 and 81% at week 12. The Subject Global Aesthetic Improvement Scale (SGAIS) showed 58% and 62.5% of patients reported the appearance of their skin was improved at week 6 and 12, respectively. Overall, there was a statistically significant improvement in skin radiance as well as improvement in overall facial aesthetics reported by both investigators and subjects. CONCLUSION: This tinted mineral based SPF50 sunscreen containing photolyase, antioxidants, and peptides is effective at repairing some clinical signs of photoaging and is well-tolerated for daily use. J Drugs Dermatol. 2022;21(5):517-520. doi:10.36849/JDD.6503.

Single-Center, Prospective, Double-Blind, Evaluator-Blind, non-Randomized, Vehicle-Controlled Trial With a 1927 Nm Non-Ablative Fractionated Laser and Topical 0.05% Tretinoin Lotion for Facial Dyspigmentation and Photodamage.

BACKGROUND: Dyspigmentation and photodamage are common concerns in patients who seek aesthetic consultation. A number of treatment modalities have been utilized to address this issue. 1927 nm thulium fiber laser is a fractionated non-ablative laser that has been shown to be safe and effective in treatment of photoaging. Topical retinoids have been used for over two decades for photoaging to promote epidermal hyperplasia and collagen synthesis and to decrease melanin production. There has been lack of data to support the combination of topical retinoids with laser treatments in the management of facial dyspigmentation and photodamage. OBJECTIVE: The primary objective of this study is to evaluate the benefits and subject satisfaction resulting from use of a 1927 nm thulium fiber laser with and without 0.05% tretinoin lotion for facial dyspigmentation and photodamage. RESULTS: Both groups showed a significant change in Investigator Assessed Overall Hyperpigmentation and Investigator Assessed Overall Photodamage over time (P<0.001). No statistically significant differences were seen between groups at any time point as measured by investigator reported and subject reported efficacy scales except for Subject Global Aesthetic Improvement Scale and Subject Satisfaction at 30 days after laser treatment, at which patients who received 0.05% tretinoin lotion reported a lower level of improvement (2.8 ± 0.86 in the treatment group vs 2 ± 0.85 in the vehicle group, P=0.009) and lower patient satisfaction when compared to the vehicle group (2.87 ± 1.55 in the treatment groups vs 1.53 ± 0.64 in the vehicle group, P=0.001). CONCLUSION: In our study, patients tolerated the combination of 1927 nm thulium fiber laser and 0.05% tretinoin lotion well. Both groups resulted in significant reduction of hyperpigmentation and photodamage. Subject satisfaction and perceived improvement were temporarily lower at 30 days only when, combining 0.05% tretinoin lotion with 1927 nm thulium fiber laser. Future studies are needed to investigate the impact on efficacy when combining laser procedures with a longer duration of use or a higher concentration of topical tretinoin. J Drugs Dermatol. 2021;20(11):1174-1179. doi:10.36849/JDD.6182.

Updates and Best Practices in the Management of Facial Erythema.

Facial erythema is a common dermatologic complaint. There are many medical and procedure-based treatments to help reduce the appearance of unwanted facial redness. The authors review a variety of treatment options and techniques to reduce facial erythema and prominent facial veins including topical medical therapies, a variety of lasers, light- and energy-based devices as well as the use of neuromodulators and sclerotherapy. The benefits and potential pitfalls of each procedure modality are also highlighted.

The Masseter Muscle and Its Role in Facial Contouring, Aging, and Quality of Life: A Literature Review.

BACKGROUND: Masseter muscle hypertrophy manifests itself as enlargement of the masseter muscle. It can be associated with a square-angled lower face, pain, dental attrition, maxillary and mandibular bone resorption, and accelerated aging process of the lower face. The objective of this study was to assess the efficacy and safety of botulinum toxin type A in contouring the masseter and its impact on quality of life and the aging process of the lower face, and its role in full face rejuvenation. METHODS: A PubMed search was conducted for articles on masseter treatment with botulinum toxin type A, masseter muscle hypertrophy, and the aging process of the lower face. Key studies are reviewed and findings are summarized. RESULTS: Botulinum toxin type A can be injected into the lower posterior aspect of the masseter muscle. Treatment decreases muscle bulk and reshapes the lower face. Furthermore, patient quality-of-life measures, including pain and symptoms of grinding and clenching, are improved. Treatment can decrease shear stress on maxillary and mandibular bones and can possibly prevent tooth loss and progressive bone resorption of the lower face. Adverse effects are minimal and short lasting. CONCLUSIONS: Botulinum toxin type A is a safe and effective treatment of masseter hypertrophy. The treatment results in improvement of functionality and cosmesis, and restoration of facial harmony.

Delayed diagnosis of post-surgical pyoderma gangrenosum: A multicenter case series and review of literature.

INTRODUCTION: Pyoderma gangrenosum is a chronic neutrophilic dermatosis which can occur following trauma or surgery and can mimic infection. Surgical intervention can lead to progression of disease. PRESENTATION OF CASES: This case series describes 3 cases of post-surgical pyoderma gangrenosum with delayed diagnosis from two large medical centers. DISCUSSION: Epidemiology, pathogenesis, clinical and histopathologic presentation, and management of post-surgical pyoderma gangrenosum are discussed with a review of the literature. CONCLUSION: Post-surgical pyoderma gangrenosum (PSPG) can mimic ulcerative disorders including bacterial infection. The diagnosis should be suspected in post-operative wounds with negative bacterial cultures which progress despite broad-spectrum antibiotics and surgical debridement. Recognizing the clinical features of PSPG is fundamental to prevent severe destruction and deformity.

Metastatic signet ring cell carcinoma of unknown primary origin: a case report and review of the literature.

In spite of the increasingly sophisticated diagnostic workup, detailed investigations fail to reveal a primary site of origin for about 3-5% of metastatic tumors. The most commonly reported subtype in cancer of unknown primary origin is adenocarcinoma. Signet ring cell carcinoma (SRCC) is a rare poorly differentiated aggressive subtype of adenocarcinoma that most commonly arise from the gastrointestinal tract. It usually presents late and is associated with poor prognosis. Treatment options remain limited to anecdotal reports. However, immunohistochemical studies can be useful in suggesting an origin and therefore may help guide investigations and treatment options. Here we present an unusual case of metastatic SRCC of unknown primary origin presenting as peritoneal carcinomatosis in a 73-year-old man. We also review the literature on metastatic SRCC of unknown primary origin and discuss the relevant findings. This work highlights the importance of collaboration between clinicians and pathologists as well as detailed histopathological, immunohistochemical, and molecular analyses which can help guide investigations and management options.

Risk of melanoma and non-melanoma skin cancer in ulcerative colitis patients treated with thiopurines: a nationwide retrospective cohort.

OBJECTIVES: There are limited data on the risk of non-melanoma skin cancer (NMSC) and melanoma skin cancer (MSC) among thiopurine-treated patients with ulcerative colitis (UC). Our aim was to investigate the risk while on, by cumulative years, and after stopping thiopurine therapy. METHODS: Nationwide data were obtained from the Veterans Affairs (VA) health-care system during 2001-2011. We performed a retrospective cohort study evaluating patients with UC. Cox regression was used to investigate the association between thiopurines use and time to NMSC while adjusting for demographics, ultraviolet radiation exposure, and VA visiting frequency. A matched nested case-control study was conducted to investigate the association between thiopurine use and MSC. RESULTS: We included 14,527 patients with UC in the analysis, with a median follow-up of 8.1 years. A total of 3,346 (23%) patients used thiopurines for a median duration of 1.6 years. We identified 421 NMSC and 45 MSC cases. The adjusted hazard ratios of developing NMSC while on and after stopping thiopurines were 2.1 (P<0.0001) and 0.7 (P=0.07), respectively, as compared with unexposed patients. The incidence rate of NMSC among those who never used thiopurines was 3.7 compared with 5.8, 7.9, 8.3, 7.8, and 13.6 per 1,000 person-years for the 1st, 2nd, 3th, 4th, and 5th year of thiopurine use, respectively. No statistically significant association was observed between thiopurine use and MSC, odds ratio 0.8 (P=0.6). CONCLUSIONS: In this predominantly white male nationwide cohort, there was a twofold increase in the risk of NMSC while on thiopurines. The incidence rate of NMSC significantly increased with subsequent years of cumulative exposure to thiopurines. Stopping thiopurines reduced the risk of NMSC to pre-exposure levels irrespective of the prior exposure duration.

Adherence and efficacy of screening for low bone mineral density among ulcerative colitis patients treated with corticosteroids.

OBJECTIVES: Ulcerative colitis (UC) is associated with an increased risk of metabolic bone disease and fragility fractures. The aim of this study was to assess the adherence to the guidelines issued by the American Gastroenterology Association (AGA) for the screening for low bone density in UC patients and to assess the benefits of dual-energy X-ray absorptiometry (DXA) screening among corticosteroid (CS)-treated UC patients. METHODS: Nationwide Veterans Affairs system (VA) data were obtained. UC patients followed up in the VA between 2001 and 2011 and the occurrence of fragility fractures were identified using International Classification of Diseases, Ninth Revision codes. Exposure to CSs was assessed using pharmacy data. DXA screening was assessed using the VA procedure database. Post DXA screening, medication use was also assessed from the pharmacy database. Cox regression analysis was performed to calculate the hazard ratio (HR) of fragility fractures among those patients who received DXA compared with those who did not. RESULTS: We included 5,736 patients. Among them, 80 (1.4%) patients suffered from fragility fractures during the follow-up period. Overall adherence rate to AGA guidelines was 23%. Adherence rate was highest among postmenopausal women (48%) and lowest among men above 50 years of age (20%). UC patients who received DXA screening were more likely to be started on bisfosfonates (P<0.001), calcitonin (P<0.001), vitamin D, and calcium (P<0.001) compared with those who did not receive screening. Those who received DXA screening were half as likely (HR=0.5, 0.3-0.9, P=0.03) to develop fragility fractures as compared with those who did not receive screening. The benefits were more prominent among those with higher CS exposure. CONCLUSIONS: Rates of DXA screening were low among CS-treated UC patients. Those who received DXA screening were more likely to be started on antiresorptive therapy and supplemental medications and had a 50% reduction in the risk of fragility fractures. More efforts should be directed toward raising the adherence to AGA guidelines and the awareness of DXA benefits.

Prevalence and predictors of low bone mineral density in males with ulcerative colitis.

CONTEXT: Low bone mineral density (BMD) is common in patients with inflammatory bowel diseases. OBJECTIVE: The objective of the study was to assess the prevalence and the predictors of low BMD (osteoporosis or osteopenia) and fragility fractures among men with ulcerative colitis. DESIGN: This was a retrospective database analysis. SETTING: The study was conducted at a nationwide Veterans Affairs health care system. PATIENTS: Male ulcerative colitis patients who were followed up in the Veterans Affairs system between 2001 and 2011 were identified using the International Classification of Diseases, ninth revision (ICD-9). MAIN OUTCOME MEASURES: We identified patients with low BMD and fragility fractures using ICD-9 codes. Steroid exposure was assessed using pharmacy data. A multivariate analysis was used to identify the independent effect of systemic steroids on the risk of low BMD and fragility fractures. RESULTS: We identified 34 665 patients. Among them, 31% used steroids. The prevalence of low BMD was 15.8% and 7.1% among those who used and did not use steroids, respectively (P < .001). Prevalence of fragility fractures was 7.9%, 4.4%, and 1.1% for those with osteoporosis and osteopenia and those without low BMD, respectively (P < .001). Steroid exposure showed a dose-response pattern, patients who had cumulative prednisone exposure of greater than 11 136 mg (10th decile) were more likely to develop low BMD (odds ratio 8.9, P < .001) and fragility fractures (odds ratio 1.8, P < .001) as compared with non-steroid users after controlling for other possible predictors. CONCLUSION: In this nationwide cohort, the prevalence of low BMD was higher than what was reported for the general male population. There was a strong correlation between the cumulative steroid use and the risk of low BMD. Both steroids and low BMD were independent risk factors for fragility fractures.