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.

Best Clinical Practices with ATX-101 for Submental Fat Reduction: Patient-related Factors and Physician Considerations.

BACKGROUND: Submental fat can be reduced with ATX-101 (deoxycholic acid injection), a customizable and minimally invasive alternative to liposuction. In the years since its approval, the treatment patterns of ATX-101 have evolved. METHODS: A panel of experienced physicians from the United States gathered to generate best practices for the use of ATX-101 in submental contouring. RESULTS: The expert panel provided their insights on appropriate patient selection, managing patient expectations of ATX-101 treatment outcomes, and adverse events, and guidance on ATX-101 administration for optimal outcomes are presented here. CONCLUSION: These best clinical practices on the use of ATX-101 for the reduction of submental fat should enable physicians to enhance the patient treatment experience and outcomes.

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.

Facial rejuvenation using Er:YAG laser equipped with a spatially modulated ablation module: A clinical, ultrasound, and histological evaluation.

BACKGROUND: A plethora of noninvasive approaches has been developed in recent years for facial rejuvenation. Energy-based devices have been one of the most popular treatments for reversing and preventing signs of facial aging such as fine lines, wrinkles, ptosis, and photoaging. AIMS: A new technology (RecoSMA) for skin rejuvenation based on acoustic-interference method using Er:YAG laser (2936 nm) equipped with a special module that targets both the dermis and the superficial musculoaponeurotic system (SMAS) was recently demonstrated to be safe and effective in facial rejuvenation. PATIENT/METHODS: In this follow-up prospective study, the clinical effects of recoSMA treatment on skin structures and SMAS were evaluated with ultrasound and histological analysis, at 30 and 90 days posttreatment. RESULTS: Treatment with recoSMA was shown to result in a significant increase in thickness of the epidermis, dermis, and SMAS layer, while levels of collagen I, III, and IV were shown to be elevated at 90 days posttreatment. CONCLUSION: Collectively, data show that treatment with recoSMA laser has a profound biological effect in stimulating and reconstructing the elastin/collagen framework necessary for preventing facial aging.

Effective noninvasive body contouring by using a combination of cryolipolysis, injection lipolysis, and shock waves.

BACKGROUND: Cryolipolysis combined with shockwave therapy has been previously shown to have synergistic effects in body contouring results. OBJECTIVE: This open-label, prospective, multicenter, comparative study investigated the safety and efficacy of combined cryolipolysis, shockwave therapy with cryolipolysis, shockwave therapy, and injection polyenylphosphatidylcholine-based lipolysis. METHODS: Enrolled patients were treated in the abdominal or flank area with cryolipolysis, shockwave therapy and injection lipolysis (n = 10) or cryolipolysis and shockwave therapy (n = 4). All treatments were conducted the same day. Evaluations were conducted 3 months after treatment and included histological analysis, standardized photography, blinded-investigator efficacy, and safety ratings, as well as patient ratings of satisfaction and tolerance. RESULTS: Compared to baseline, the 3-month follow-up histological analysis revealed a more profound subcutaneous adipose tissue reaction with the triple combination therapy (cryolipolysis, injection lipolysis, radial shock wave) than with the double combination with regard to adipocyte damage and grade of inflammation. Waist circumference was significantly reduced in patients of both groups, but patients in the triple combination group were shown to have a significantly more pronounced reduction in subcutaneous fat. Factors that were shown to influence treatment outcome included baseline BMI and waist circumference. Age and gender had no effect. The abdominal area reacted better to the treatment compared to flanks. No significant side effects or adverse events were reported. The procedure was well-tolerated, and the majority of patients were satisfied with the treatment results. CONCLUSIONS: Combination of cryolipolysis, radial shockwave, and injection lipolysis is a safe, well-tolerated treatment for reduction in subcutaneous fat.

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.

Structural Gender Dimorphism and the Biomechanics of the Gluteal Subcutaneous Tissue: Implications for the Pathophysiology of Cellulite.

BACKGROUND: This study was performed to investigate gender differences in gluteal subcutaneous architecture and biomechanics to better understand the pathophysiology underlying the mattress-like appearance of cellulite. METHODS: Ten male and 10 female body donors [mean age, 76 ± 16.47 years (range, 36 to 92 years); mean body mass index, 25.27 ± 6.24 kg/m (range, 16.69 to 40.76 kg/m)] were used to generate full-thickness longitudinal and transverse gluteal slices. In the superficial and deep fatty layers, fat lobule number, height, and width were investigated. The force needed to cause septal breakage between the dermis and superficial fascia was measured using biomechanical testing. RESULTS: Increased age was significantly related to decreased dermal thickness, independent of sex (OR, 0.997, 95 percent CI, 0.996 to 0.998; p < 0.0001). The mean number of subdermal fat lobules was significantly higher in male body donors (10.05 ± 2.3) than in female body donors (7.51 ± 2.7; p = 0.003), indicating more septal connections between the superficial fascia and dermis in men. Female sex and increased body mass index were associated with increased height of superficial fat lobules. The force needed to cause septal breakage in male body donors (38.46 ± 26.3 N) was significantly greater than in female body donors (23.26 ± 10.2 N; p = 0.021). CONCLUSIONS: The interplay of dermal support, septal morphology, and underlying fat architecture contributes to the biomechanical properties of the subdermal junction. This is influenced by sex, age, and body mass index. Cellulite can be understood as an imbalance between containment and extrusion forces at the subdermal junction; aged women with high body mass index have the greatest risk of developing (or worsening of) 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.

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.

Radiofrequency Technology in Face and Neck Rejuvenation.

Three doctors discuss the current issues and controversies involving the use of radiofrequency and energy-based devices for skin tightening, facial contouring, and other indications. The use of transcutaneous monopolar-, bipolar-, multipolar-, subcutaneous-, and microneedle-based delivery methods are discussed. The controversies involved in the various devices are discussed.

Optimizing outcomes with polymethylmethacrylate fillers.

INTRODUCTION: The ideal filler should be long-lasting, biocompatible, chemically inert, soft and easy to use, and have a long history of safety. This review focuses on the evolution and development of the PMMA-collagen gel, Bellafill, and the 10 years of postmarketing experience of Bellafill since it received premarket approval (PMA) from the FDA as Artefill in 2006. Artefill was rebranded to Bellafill in 2015. METHODS: The authors conducted a literature search on PubMed for key articles describing the steps in which Arteplast, a PMMA filler developed in 1989, led to the development of Bellafill, the only PMMA filler approved by the US FDA for the treatment of nasolabial folds and acne scar correction. The factors governing efficacy and safety were also evaluated for the major PMMA fillers available in the world. RESULTS: The process of manufacturing and purifying PMMA has played a major role in minimizing adverse events for Bellafill. Postmarketing surveillance data for the 2007-2016 period show that for more than 530 000 Bellafill syringes distributed worldwide, 11 confirmed granulomas (excluding clinical trial data) (0.002% of syringes sold) have been reported. Data on other PMMA fillers are limited and inconsistent. The authors suggest that adverse events are often attributable to lack of proficiency in treatment technique and other factors. CONCLUSION: Bellafill has demonstrated an excellent safety and effectiveness profile in multiple clinical studies, customer feedback, and 10 years of postmarketing surveillance experience. Adverse events occur with all fillers for a variety of reasons. In addition to quality of the product, injector skill and technique are critical to ensuring good clinical outcomes.

The Pathophysiology of the Male Aging Face and Body.

Increasing numbers of men are seeking aesthetic treatments for fat reduction, skin rejuvenation, and other antiaging goals. Compared with women, however, men have distinctly different anatomy and physiologic differences that manifest in the aging process. Given that both anatomy and the aging process affect treatment strategies and clinical outcomes, there is a need for dermatologists to be acutely aware of these male-specific nuances to provide the best clinical care and patient satisfaction.

Volumetric Structural Rejuvenation for the Male Face.

Fillers and toxins are safe, quick, and require no downtime; the immediately visible results can boost a man's self-esteem, confidence, youthfulness, and sense of competitiveness in the personal and professional realms of the world. The approach to using these agents has changed from ironing out the skin to remove wrinkles and lines to a restructuring of the 3-dimensional face. This new strategy, volumetric structural rejuvenation (VSR), relies on intimate knowledge of facial anatomy and the pathophysiology of aging. It is of essence to know the key anatomic differences between the 2 sexes to avoid potential feminization.

New-Generation Therapies for the Treatment of Hair Loss in Men.

Hair loss affects millions of people worldwide and can have devastating effects on an individual's psychoemotional well-being. Today hair restoration technologies through hair transplantation have advanced with the use of robots and follicular unit extraction/grafting that can offer patients excellent clinical results. Adjuvant modalities, such as platelet-rich plasma injections, lasers, and stem cells, can further enhance durability, health, and appearance of hair transplants.

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.

Physician-Industry Collaboration: Organizational Considerations for the Future of Innovation and Growth in Dermatology.

The U.S. medical environment continues to evolve with issues from Privacy to EMR, Insurance regulations, Physician Access and Healthcare Reform, and MACRA (Medicare Access and CHIP Reauthorization Act) on the discussion table. Not since the advent of Medicare and Medicaid in the mid 1960's, have we seen such widespread changes in the medical healthcare environment (Centers for Medicare and Medicaid Services). Physicians, industry, patients and consumers are affected by the changes. These four groups have historically worked as separate entities, but are now key stakeholders in the future of dermatology. As stakeholders collaborating in building a future together, the dermatologists/physicians will help to ensure and preserve the quality of patient care and best patient outcomes. In 2 Executive Forum meetings February 21-23, 2014 and June 3-4, 2016 the leaders from the Women's Dermatologic Society and Industry, explored several important areas, six of which will be reviewed in this article 1) A five-year outlook of Dermatology and Medicine; 2) The New Practice Environment; 3) Access of Industry to Dermatologists and Trainees; 4) Doing Things Differently; and 5) Female Leadership 6) Unmet Needs. The collaborative group explored solutions for our specialty and the patients we serve.