Treatment of Atrophic Facial Acne Scars With Microneedling Followed by Polymethylmethacrylate-Collagen Gel Dermal Filler.

BACKGROUND: Microneedling and soft-tissue filler injections have been used independently to improve acne scarring. The effectiveness of a combined approach using microneedling followed by polymethylmethacrylate (PMMA)-collagen gel has not been carefully studied. OBJECTIVE: The goal of this study was to assess the effectiveness and safety of microneedling alone versus microneedling followed by injection of PMMA-collagen gel filler for correction of atrophic facial acne scars. METHODS: We conducted a multicenter, open-label, randomized, prospective study on subjects with distensible atrophic acne scars in the face to determine whether microneedling with PMMA-collagen gel is a superior acne scar treatment over microneedling alone. Forty-four subjects received 3 microneedling treatments over a 12-week period followed by randomization to treatments with PMMA-collagen gel (treatment group) or no further treatment (control group). RESULTS: At 24 weeks, the treatment group achieved a statistically significant improvement in acne scores over microneedling alone. The improvement continued at 36 weeks. At 24 weeks, the treatment group showed a strong trend in improvement on the Physician Global Aesthetic Improvement Scale compared with microneedling alone.

Platelet-Rich Plasma (PRP): Current Applications in Dermatology

Platelet-rich plasma (PRP) is an autologous serum containing high concentrations of platelets and growth factors. PRP continues to evolve as an important treatment modality with many applications in dermatology, particularly in the areas of hair restoration, skin rejuvenation, acne scars, dermal augmentation, and striae distensae. Furthermore, combining PRP with laser therapies, microneedling, dermal fillers, and autologous fat grafting produces synergistic effects, leading to improved aesthetic results. Future studies should standardize PRP treatment protocols for specific indications. PRP holds considerable promise in dermatology with therapeutic applications continuing to expand.

Combination Therapy for Acne Scarring: Personal Experience and Clinical Suggestions.

Acne is one of the most prevalent skin conditions seen by dermatologists. The cosmetic sequelae of severe acne, including scarring and pigmentation, have a profound psychological impact on those in icted. Topical (eg, retinoids, antibiotics, dapsone, hydroxyacids) and oral treatments (eg, antibiotics and/or spironolactone) are often bene cial to control acne or in the instance of oral isotretinoin use, rid the acne permanently; however, these treatments have very little affect on the ultimate cosmetic outcome of the acne scarring and skin texture that results. Given the variety of scar types that can form and the variability of responses seen in various skin types and textures, treatment options are vast without appropriate guidelines for pathways that dictate best timing, combinations, and options in given clinical scenarios. Current treatment options include solo or combina- tions of energy-based (eg, laser, radiofrequency), chemical-based (eg, peels, TCA cross), surgical-based options (eg, subcision, punch excision), microneedling, and llers and/or fat injections. Most recently, fractional radiofrequency-based treatments have been used to improve acne scarring with less reported downtime as compared to lasers or chemical peels and the ability to treat darker or sensitive skin types with less risk of scarring or hyperpigmentation. In severe cystic ares, scarring treatments are often postposed till the acne is under control and in many instances this can limit the dermatologists ability to affect future cosmetic treatments. Based on personal experience of various clinical scenarios in a busy laser practice that treats a signi cant number of patients with acne scarring, fractional radiofrequency is an excellent choice for treating all forms of acne scars with minimal risk to patients, even those on concurrent treatments such as isotretinoin. Additionally, fractional radiofrequency can be used in combination with all other treatment options to speed the time to clinical improvement appreciated by the patient. Here we present personal experiences of combination treatments for acne scarring, pigmentation and textural issues, and suggest that fractional radiofrequency be considered a "gold standard" treatment of acne scarring in those with dark or sensitive skin types or those on concurrent isotretinoin. J Drugs Dermatol. 2016;15(11):1413-1419..

Extracellular Matrix Modulation: Optimizing Skin Care and Rejuvenation Procedures.

Normal aging and photoaging of the skin are chronic processes that progress gradually. The extracellular matrix (ECM), constituting over 70% of the skin, is the central hub for repair and regeneration of the skin. As such, the ECM is the area where changes related to photodamage are most evident. Degradation of the ECM with fragmentation of proteins significantly affects cross talk and signaling between cells, the matrix, and its constituents. The accumulation of collagen fragments, amorphous elastin agglutinations, and abnormal cross-linkages between the collagen fragments impedes the ECM from its normal repair and regenerative capacity, which manifests as wrinkled, non-elastic skin. Similar to how the chronic wound healing process requires wound bed preparation before therapeutic intervention, treatment of chronic aging of the skin would likely benefit from a "skin bed preparation" to optimize the outcome of rejuvenation procedures and skin maintenance programs. This involves introducing agents that can combat stress-induced oxidation, proteasome dysfunction, and non-enzymatic cross linkages involved in glycation end products, to collectively modulate this damaged ECM, and upregulate neocollagenesis and elastin production. Agents of particular interest are matrikines, peptides originating from the fragmentation of matrix proteins that exhibit a wide range of biological activities. Peptides of this type (tripeptide and hexapeptide) are incorporated in ALASTIN™ Skin Nectar with TriHex™ technology (ALASTIN Skincare, Inc., Carlsbad, CA), which is designed to target ECM modulation with a goal of optimizing results following invasive and non-invasive dermal rejuvenating procedures.

Synergistic Approaches to Neck Rejuvenation and Lifting.

There is an increasing trend shifting the aesthetic focus downward from the face with a significant number of new treatments aimed at the aging neck and below. Clinical characteristics of neck youth include clear skin texture and tone without laxity or fat, in addition to a well-defined cervicomental angle and distinct mandibular border. Similarly to treating facial aging, the neck requires a comprehensive assessment of all factors involved in the aging process--loss of volume, increased skin laxity, worsening texture and clarity, and crepe skin/wrinkling--as each requires a combination approach for improvement. It is essential to address each above factors for more than minimal improvement. A multitude of options including neuromodulators, energy based devices, surgery, and injectable agents for fat reduction are available in our armamentarium and understanding these options solo, or ideally in combination, is essential for best practice and optimal results. Herein, we describe synergic approaches to the treatment of neck aging.

Update on the Management of Rosacea.

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Steroid-sparing properties of emollients in dermatology.

Topical corticosteroids (TCS) and topical calcineurin inhibitors (TCIs) are very effective treatments in inflammatory dermatoses, but carry risks with long-term use. TCS are associated with cutaneous atrophy and tachyphylaxis and TCIs can be irritating and contain a black box warning of an increased risk of cancers including lymphoma and non-melanomatous skin cancers. Nevertheless, they are appropriate treatments for inflammatory conditions such as psoriasis and atopic dermatitis (AD) and should be used more often with disease flares and less as maintenance therapy. Given the associated risks of long-term continuous use with these pharmacologic agents, alternatives are needed with similar anti-inflammatory and barrier repair properties that can be used indefinitely without risk. Some over-the-counter (OTC) ingredients such as colloidal oatmeal and petrolatum, as well as anti-inflammatory prescription moisturizers (medical device creams), have demonstrated efficacy with little complications in skin barrier repair and symptom relief in steroid-responsive conditions. With regimented application, these non-drug options are safe and effective and can limit the longterm continuous use of TCS or TCIs.

Aesthetic applications of calcium hydroxylapatite volumizing filler: an evidence-based review and discussion of current concepts: (part 1 of 2).

BACKGROUND: Calcium hydroxylapatite filler (CaHA; Radiesse) is a synthetic, non-animal derived product composed of minerals that occur naturally in bone and teeth. Following its development in the US, initial approval by the US FDA for non-aesthetic indications and CE marking in Europe, it was used off FDA-labeling for aesthetic purposes. Its use has grown further since its FDA approval in 2006 for long-lasting correction of moderate to severe wrinkles and folds. It is a popular filler for volume restoration to the face, and also to nonfacial areas such as the dorsum of the hands. METHODS: The first article of this two-part series provides an evidence-based review of study data pertaining to the mechanism of action and biocompatibility of CaHA filler, and its safety, efficacy and tolerability when used for aesthetic purposes. The review includes data from a number of prospective, controlled comparative studies, from several retrospective studies, and from a meta-analysis of reported complications from alloplastic filler procedures over a 20-year period. The study methodology and number of study subjects are sufficiently robust to provide a high Evidence Level for much of the data. RESULTS: CaHA has good safety, efficacy and tolerability profiles that are comparable to those of hyaluronic acid (HA) fillers. It provides an initial, immediate volume replacement for up to 12 months followed by longer term correction due to biostimulation, resulting in collagenesis. Evidence Level II studies show longevity of 30 months or more after nasolabial fold implantation. Other studies demonstrate the appropriateness of CaHA filler for volume restoration to areas including the mid face, lower face and hands. CaHA is classified as an adjustable filler, whereas HA is fully reversible by hyaluronidase digestion. For this reason, and also because of CaHA's high viscosity and elasticity, evidence-based and experiential consensus suggests its avoidance in highly mobile areas (e.g. lips) or in anatomically unforgiving areas (e.g. the periocular region), where there may be increased incidence of nodules. CONCLUSION: CaHA filler is safe, efficacious and well-tolerated when used appropriately. It is increasingly recognized that many patients require pan-facial volume restoration, and that many can benefit from combined treatments. Therefore, CaHA and HA fillers may be considered complementary rather than competitive to each other. The second article of this series offers a discussion of product characteristics, scientific principles and injection techniques to optimize treatment with CaHA filler, including special considerations for avoidance and management of complications.

A case of lymphangioma circumscriptum successfully treated with electrodessication following failure of pulsed dye laser.

Lymphangioma circumscriptum is the most common cutaneous lymphatic malformation. It presents as a well-circumscribed, localized region of vesicles that can ooze and drain lymphatic and sanguineous fluid. The vesicles cause significant morbidity and psychological distress from itching, pain, drainage, and secondary infection. We report a case of a 16-year-old female with a life-long history of a weeping, hemorrhagic, and painful lesion on her right buttock causing significant emotional distress. We initially attempted therapeutic treatment with pulsed dye laser. The lesion appeared unchanged after two trials and we subsequently used three sessions of electrodessication to cauterize the aberrant vessels. The lesion largely resolved without complications and is no longer causing pain or emotional distress.

Assessment of safety and efficacy of a bipolar fractionated radiofrequency device in the treatment of photodamaged skin.

BACKGROUND: A number of devices are available for skin rejuvenation and conventional devices include both ablative and non-ablative lasers. More recently, bipolar fractionated radiofrequency (RF) devices have been introduced. OBJECTIVE: To evaluate the safety and efficacy of a novel 144 pin high density tip bipolar fractionated radiofrequency (RF) device for skin rejuvenation in Fitzpatrick skin types I-IV. METHODS AND MATERIALS: This single-center, prospective, study enrolled 25 female between the ages of 35-60 years, with mild to moderate wrinkling based on the Fitzpatrick Wrinkle Scale. The subjects were of Fitzpatrick skin types I-IV. Each subject underwent 3 full-face treatments with a 144 pin fractional bipolar RF device at 30-day intervals. All subjects underwent clinical evaluations during the study period to evaluate for any adverse events. Subsequently, all subjects were evaluated for improvement in rhytides, dyschromias and skin texture based on photographic evaluation by blinded investigators at 6 months following the final RF treatment. RESULTS: A statistically significant improvement in rhytides, dyschromias and texture was noted. Adverse events were limited to mild erythema and swelling. Post-inflammatory pigmentary changes were not observed in any subjects. CONCLUSION: The novel 144 pin high density tip bipolar fractionated RF device is both safe and effective for facial skin rejuvenation in Fitzpatrick skin types I-IV.

Novel treatment of female-pattern androgenetic alopecia with injected bimatoprost 0.03% solution.

Female-pattern androgenetic alopecia is a very common disorder that has been associated with extreme psychological morbidity. Few treatments have documented utility and many physicians are often overwhelmed with how little is pharmacologically available to treat this condition. Novel treatments that are effective, safe, less costly and simple are in high demand. We report a case of female-pattern androgenetic alopecia that failed to respond to a novel treatment with injected bimatoprost solution. Hypothetically, the treatment should have been effective and although we did not have success, this report suggests critical points to consider in the future of prostaglandin analogs, as well as other therapies being considered for the treatment of female-pattern hair loss.

A bilateral comparison study of pimecrolimus cream 1% and a topical medical device cream in the treatment of patients with atopic dermatitis.

Corticosteroids are the mainstay of therapy for atopic dermatitis, but long-term use is associated with adverse effects. We sought to evaluate the clinical efficacy of two steroid-sparing creams for atopic dermatitis. Twenty patients were enrolled in an investigator-blinded, bilateral comparison study. Patients applied pimecrolimus cream twice daily to a target lesion on one side of the body and also applied a topical medical device cream three times daily on a symmetrical target lesion on the opposite side of the body for four weeks. Clinical assessments including Physician Global Assessment (PGA), Target Lesion Symptom Score (TLSS), subject self-assessment and digital photography were performed at the baseline, 2 week, and 4 week visits. Seventy-five percent of patients (pimecrolimus, 15 of 20; topical medical device, 15 of 20) were rated "clear" (0) or "almost clear" (1) by PGA for both medications after four weeks. Percent improvement of the PGA from randomization for pimecrolimus cream and the topical medical device cream were 72.50 and 71.67 respectively (P=0.9283). PGA scores decreased significantly from baseline for both treatments (P=0.004). Overall, there was no statistically significant difference between treatment groups for PGA scores throughout the study (P=0.8236). No cutaneous side effects were noted. Our study was limited by a small sample size and lack of double-blinding; however, both treatments were found to be safe and effective in treating atopic dermatitis over four weeks. Significant improvements were noted for all efficacy variables. In conclusion, a lipid-rich, non-steroidal, topical medical device cream was as effective in improving atopic dermatitis as pimecrolimus cream.

Prospective new biologic therapies for psoriasis and psoriatic arthritis.

Psoriasis and psoriatic arthritis are immune-mediated, chronic, inflammatory diseases that place a heavy burden on the lifestyle of patients affected. Current understanding of the pathophysiology of these conditions has produced very encouraging new medical developments, largely a consequence of research that has targeted precise elements of the immune cascade, expanding the repertoire of therapeutic options available to dermatologists. Promising new treatments, such as antibodies to interleukin-12 and -23, show superior efficacy and safety in treating psoriasis; the more sophisticated tumor necrosis factor antagonists significantly improve symptoms of rheumatic and psoriatic arthritis and may also be effective in the treatment of plaque psoriasis. In this article, innovative, new treatments for psoriasis and psoriatic arthritis are critically reviewed.

Perioperative management of medications for psoriasis and psoriatic arthritis: a review for the dermasurgeon.

BACKGROUND: Psoriasis affects an estimated 3% of the world's population. Many are on chronic immunosuppressive therapy for the cutaneous and joint manifestations of this disorder. The management of these medications in the perioperative period is controversial. Psoriasis and psoriatic arthritis medications can affect wound healing, hemostasis, and infection risk during cutaneous surgery. OBJECTIVES: The objective of this article is to provide a critical review of various medications used for care of the psoriatic patient and their potential effect on cutaneous surgical procedures. CONCLUSIONS: This review summarizes current understanding of wound healing, hemostatic effects, and infectious risks regarding many psoriasis medications including nonsteroidal anti-inflammatory drugs, cyclooxygenase inhibitors, corticosteroids, various immunosuppressants, and biologic response modifiers. Recommendations vary depending on the agent in question, type of procedure, and comorbid conditions in the patient. Caution is advised when using many of the medications reviewed due to lack of human data of their effects in the perioperative period.

Sports Dermatology: Part 1 of 2 Traumatic or Mechanical Injuries, Inflammatory Conditions, and Exacerbations of Pre-existing Conditions.

Competitive athletes endure extreme bodily stress when participating in sports-related activities. An athlete's skin is particularly susceptible to a wide array of repetitive physical and environmental stressors that challenge the skin's protective function. Many unique dermatoses are well-known to the serious athlete due to countless hours of intense physical training, but are frequently unrecognized by many healthcare professionals. Sports dermatology is a distinctive, budding field of dermatology that focuses on dermatoses frequently encountered in athletes. Athletic skin problems are notoriously infectious in nature due to the inherent environment of close-contact physical activity. Nonetheless, other skin conditions can manifest or worsen with recurring mechanical or traumatic injury or exposure to environmental hazards. Additionally, sports-related activities may exacerbate other pre-existing dermatological conditions that may possibly be unknown to the athlete or clinician. The objective of this two-part review is to arm the astute physician with the fundamental knowledge of the range of dermatological conditions distinct to the competitive athlete. Knowledge of these cutaneous conditions in the context of specific sporting events will permit the clinician to manage these unique patients most effectively. Part one will focus on traumatic or mechanical injuries, inflammatory conditions, and exacerbations of pre-existing conditions frequently seen in athletes.