Treatment recommendations for acne-associated hyperpigmentation: Results of the Delphi consensus process and a literature review.

Acne vulgaris can be associated with hyperpigmentation, particularly in individuals with skin of color. This acne-induced macular hyperpigmentation (AMH), also called postinflammatory hyperpigmentation, is often long lasting and negatively impacts quality of life. Large-scale, randomized, controlled clinical trials with regard to the treatment of acne and AMH are lacking. For this reason, evidence-based treatment recommendations cannot be made. However, AMH is a common condition, and it is important for clinicians to have guidance on management strategies. The authors, a group of 10 board-certified dermatologists, conducted a modified Delphi consensus process to reach a consensus on first-line therapy for AMH and determine whether therapeutic choices change in different patient subgroups. We reached a consensus that most patients with acne and AMH should receive early and efficacious acne treatment with a topical retinoid and benzoyl peroxide. Therapies aimed at addressing AMH-including hydroquinone, azelaic acid, chemical peel, or antioxidants-may also be considered for enhancing the effect of the treatment regimen on acne and pigmentation. Chemical peels may be used as adjunctive or second-line therapy. This article details the results of the Delphi process, reviews relevant literature for providing recommendations for AMH, and discusses appropriate treatment options.

Review of the microbiome in skin aging and the effect of a topical prebiotic containing thermal spring water.

BACKGROUND: Interest in the skin microbiome and the cosmetic benefits of probiotics, prebiotics, and postbiotics is increasing. AIM: The current review explores the influence of the skin microbiome on facial skin aging and the effects of oral and topical probiotics, prebiotics, and postbiotics use on skin aging and cosmetic outcomes. METHODS: Five dermatologists who treat clinical signs of facial skin aging and a microbiome scientist (advisors) explored the relationship between the skin microbiome and skin aging. Published evidence and the advisors' knowledge lead to guidance on the skin microbiome using oral and topical prebiotics, probiotics, and postbiotics to reduce signs of aging. RESULTS: The role of the microbiome in aging skin is an emerging concept. A diverse skin microbiome is essential for skin health. Preliminary studies suggest oral probiotics and prebiotics may play a role in reducing signs of skin aging, likely through shifting to a greater skin and gut microbiome diversity. Thermal spring water contains probiotics and prebiotics. Preliminary studies suggest topically applied probiotics, prebiotics, and postbiotics may improve signs of skin aging, including a reduction in fine lines and increased hydration. CONCLUSIONS: The panel agreed that oral and topical prebiotics, probiotics, and postbiotics may play a role in improving signs of aging by improving the skin microbiome. Larger studies with more prolonged treatment trials are needed to better understand the microbiome's role in skin aging and the possible benefits of prebiotics, probiotics, and postbiotics use.

Topical Treatments for Melasma and Their Mechanism of Action.

Objective: We conducted a review of topical agents currently used in melasma, discussing their mechanism of action, efficacy, safety, and tolerability, with an update on newer treatments. Methods: A systematic review from PubMed database was performed, using PRISMA guidelines. The search was limited to English and Spanish studies that were double or single blinded, prospective, controlled or randomized clinical trials, reviews of literature, and meta-analysis studies. Results: 348 studies were analyzed; 80 papers met inclusion criteria. Triple combination (TC) therapy and hydroquinone (HQ) are still the most well-studied agents with strong evidence-based recommendation. TC therapy remains the gold standard of care based on efficacy and patient tolerability. Evidence has shown ascorbic acid, azelaic acid, glycolic acid, kojic acid, salicylic acid, and niacinamide to be effective as adjuvant therapies with minimal side effects. Tranexamic acid (TA) and cysteamine have become recent agents of interest due to their good tolerability, however more trials and studies are warranted. Less evidence exists for other topical agents, such as linoleic acid, mulberry extract oil, rucinol, 2% undecylenoyl phenylalanine, and epidermal growth factors agents. Limitations: Some studies discussed represented a low sample size, and there is an overall lack of recent studies with larger populations and long-term follow up. Conclusions: TC therapy continues to be the gold standard of care. Topical cysteamine and TA are newer options that can be incorporated as adjuvant and maintenance treatments into a patient's regimen. Cysteamine and topical TA have no known severe adverse effects. Evidence comparing other topical adjuvant treatments to HQ, maintains HQ as the gold standard of care.

The Pathogenesis and Management of Acne-Induced Post-inflammatory Hyperpigmentation.

Acne vulgaris is a common inflammatory disease. Among patients with darker skin phototypes (Fitzpatrick III-VI), the inflammatory processes of acne stimulate excess melanogenesis and abnormal melanin deposition, leading to pigmentary sequelae known as post-inflammatory hyperpigmentation and post-inflammatory erythema in all skin tones, although post-inflammatory hyperpigmentation is more common in darker skin and post-inflammatory erythema in lighter skin. These pigmentary alterations can be long lasting and are often more distressing to patients than the active acne lesions. This article discusses what is known about acne-related pigmentation, much of which is extrapolated from general study of nonspecific pigment deposition. Because dyspigmentation poses both a significant clinical concern to patients and a therapeutic challenge to clinicians, we formed a working group consisting of pigmentary experts with the aim of increasing awareness and education of acne-related pigmentary sequelae.

Update on the Treatment of Scars

Background: Treatment of scars continues to be a persisting challenge. Scar classification is paramount in determining an appropriate treatment strategy. They can be classified into hypertrophic, keloid, or atrophic scars. With the increasing demand for less invasive procedures that result in equal or greater outcomes, there has been an increase in the variety of procedures for the management of scarring. Methods: A Pubmed search was performed for the most recent papers on scar treatments. Findings and applications are discussed in this review. Results: Studies evaluating the efficacy and safety of microneedling, filler agents, toxins, silicone gels, and laser devices such as ablative, non-ablative, fractional, SRT, and radiofrequency are discussed. Conclusion: Review of the literature revealed a myriad of options for the treatment of different scar types. Although there is not vast evidence in the literature in regard to combination treatments, these are becoming more popular, and it is the author's opinion that combination treatments yield better overall results. J Drugs Dermatol. 2019;18(6):550-555.

Comparison of a novel wound dressing vs current clinical practice after laser resurfacing.

BACKGROUND: There are many postprocedure skin care options, but no consensus on the best formulation to optimize healing. Silicone gels have only been used to treat keloids and hypertrophic scars and typically applied after the wound has healed. This study compared the healing response after fractional ablative erbium laser resurfacing with a petrolatum-based ointment and a silicone gel. METHODS: A randomized, open-label, split-face study was performed. Ten subjects underwent Erbium:YAG (Sciton) fractional laser resurfacing. Patients were randomized to apply a petrolatum-based gel or a silicone gel (Stratacel® ; Stratpharma) on either the right or left side of the face. Subjects applied the products twice a day for 7 days and were evaluated in person 7, 30, and 60 days postprocedure. Subjects reported on the overall general aesthetic outcome, perceived pain, itch, and tightness via questionnaires using the Global Aesthetic Improvement Scale and the Wrinkle Severity Rating Scale (WSRS). RESULTS: All subjects healed without complications. By day 60, there was no difference in signs and symptoms of healing between the two different dressing approaches. However, patients treated with the silicone gel had less post-treatment erythema and hyperpigmentation. CONCLUSIONS: A novel silicone gel resulted in reduced signs of erythema and hyperpigmentation postprocedure, without an increase in adverse events. Additionally, the silicone gel dries to form a thin, full contact film and can be covered with sunscreen or cosmetics once dry. This new silicone gel presents a good option for postprocedure care after ablative fractional laser resurfacing.

Novel topical dermal repair: A clinical analysis.

BACKGROUND: There is an increasing interest in and demand for noninvasive anti-aging treatments, and cosmeceuticals are an effective adjunct treatment to in-office cosmetic treatments. OBJECTIVE: This study evaluates the short-term cosmetic benefits of a topical anti-wrinkle cream (Ultrascript Dermal Regenesis, Montclair, NJ) and a topical evening DNA repair serum (Dermal DNA Repair Serum with the active ingredient AC-11 from Optigenex INC). METHODS: Fourteen women of all Fitzpatrick skin types were randomized to receive either the topical anti-wrinkle cream (AM cream) only or the AM cream and the topical evening DNA repair serum (PM serum) for 16 weeks. Subjects noted their subjective improvement in wrinkles, pore size, hyperpigmentation, and overall skin quality. Two blinded physicians evaluated the appearance of wrinkles pre- and postapplication of the AM cream. RESULTS: Participants who applied the AM cream only reported subjective improvement in wrinkles and overall quality of their skin. Immediate improvement of wrinkles was seen after the application of the AM cream. Subjects who applied both the AM cream and PM serum noted improvement in pore size. CONCLUSION: This novel anti-wrinkle cream is a safe and effective topical treatment for the immediate, but short-term improvement of wrinkles. Prolonged use of the cream and continued follow-up may show additional long-term benefits.

Evaluating the Effects of Injected Calcium Hydroxylapatite on Changes in Human Skin Elastin and Proteoglycan Formation.

BACKGROUND: Previous studies have shown that calcium hydroxylapatite (CaHa) injected intradermally resulted in new collagen production at 6 months after injection, and a possible increase in elastin formation. In addition, a recent study showed the formation of new collagen, elastin, and angiogenesis after injection at 4 and 9 months. OBJECTIVE: To evaluate any changes in the presence of elastic fibers, proteoglycans, and elastin in photodamaged skin after injections with CaHa. METHODS AND MATERIALS: Fifteen subjects underwent a punch biopsy of the right infra-auricular areas before and after injection of CaHa on day 180. Specimens were stained for elastic fibers, elastin, and proteoglycan presence. RESULTS: Quantitative analysis demonstrated a percent change in elastic fibers varying between 29% and 179% at 6 months in comparison with baseline. Subjects showed an increase in elastin between 12% and 66%. Subjects had positive mean percentage change in proteoglycans of 76.27% (t-test of 0.198). CONCLUSION: This is the first study to show that CaHa can increase proteoglycans and echoed previous studies showing it can also have an effect on elastin, which indicates it can induce remodeling of all aspects of the extracellular matrix. Much larger and longer studies are required to confirm its unique impact on collagen, elastin, and proteoglycans.

Use of a novel 589-nm solid-state laser for treatment of facial erythema.

OBJECTIVE: To evaluate the efficacy and safety associated with use of a 589-nm solid-state laser for treatment of facial erythema. METHODS: A prospective, IRB-approved study was conducted. Participants who were interested in treatment for facial erythema were recruited. They received four monthly treatments with the 589-nm laser. Erythema of the right and left face was graded on a scale of 0-4, 4 being most severe, by both investigators and participants prior to each treatment and at follow-up. Safety was assessed by any reported side effects. RESULTS: Twenty-four participants enrolled in the study, 16 women (67%) and 8 men (33%), with an average age of 51.1 years. Investigator grades showed a statistically significant improvement in erythema of 31% for both the right and left face. Participant grades showed a statistically significant improvement in erythema of 23.2% for the right face and 22.8% for the left face. Side effects were limited to transient erythema posttreatment. CONCLUSION: A 589-nm solid-state laser achieved a modest improvement in facial erythema when evaluating results 1 month after four monthly treatments. No major safety issues were reported.

Novel melanoma therapies and their side effects.

In the last few years, melanoma treatment has been revolutionized by the development of immune checkpoint-blocking antibodies or immune checkpoint inhibitors including ipilimumab, vemurafenib, dabrafenib, trametinib, nivolumab, and pembrolizumab. Although they have shown promising results, they also have caused multiple adverse events (AEs), particularly immune-related AEs (irAEs). Specialists should be familiar with these AEs.

Natural Cosmeceutical Ingredients for Hyperpigmentation.

As Dermatologists caring for patients with hyperpigmentation problems, we are always looking for more alternative therapies. Hydroquinone (HQ) is still the standard of care. However, traditional depigmenting agents such as HQ and corticosteroids, although highly effective, can raise safety concerns including exogenous ochronosis, atrophy, carcinogenesis and local and systemic untoward effects with long term use. Therefore, we need to investigate non-prescription natural alternatives. This manuscript presents many of the natural ingredients found in cosmeceuticals for the treatment of hyperpigmentation and their mechanisms of action. It will also describe the melanocyte activation pathways and how each of these ingredients interferes with it.