Alternative Cosmetic and Medical Applications of Injectable Deoxycholic Acid: A Systematic Review.

BACKGROUND: Beyond submental fat reduction, injectable deoxycholic acid (DCA) has gained popularity in recent years for various minimally invasive lipolysis applications. OBJECTIVE: To summarize and evaluate the evidence of off-label uses of injectable DCA. METHODS: MEDLINE, Embase, CINAHL, Web of Science, and CENTRAL were searched. The outcomes measured included applications of DCA, treatment regimen, and its efficacy. An overall success rate for each condition was calculated based on the improvement defined in the included studies. RESULTS: Eleven studies evaluated the cosmetic use of DCA for excess adipose tissue on various anatomical locations. The outcomes were evaluated at time points ranging from 1 to 21 months post-treatment, with overall success rates over 85%. Eight case reports and series reported the success of using DCA treating lipomas, xanthelasmas, paradoxical adipose hyperplasia, fibrofatty residue of infantile hemangioma, piezogenic pedal papules, and HIV-associated lipohypertrophy. Although the preliminary efficacies were high, the overall recommendations for off-label uses are weak because of the lack of high-level studies. CONCLUSION: The review emphasizes the diversity of injectable DCA as a minimally invasive technique for lipolysis. Further high-level studies demonstrating consistent treatment regimens and methods of evaluation are warranted to make more definitive recommendations regarding off-label DCA use.

Microneedling Treatment of Striae Distensae in Light and Dark Skin With Long-Term Follow-Up.

BACKGROUND: Striae distensae have notoriously been difficult to treat due to their extensive involvement of nonfacial skin. Microneedling with its lack of thermal injury during microneedling treatment renders it a viable treatment option in darker skin tones and nonfacial regions due to the reduced risk of postinflammatory hyperpigmentation. OBJECTIVE: To describe the clinical results and side effects of microneedling in a series of 25 individuals with striae distensae. MATERIALS AND METHODS: Twenty-five consecutive adults (SPT I-V) with striae distensae involving the trunk and extremities were treated using a microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of striae on a 5-point scale. Side effects were monitored and tabulated. RESULTS: Patients received 1 to 3 consecutive monthly treatments. All striae improved at least 50% after an average of 1.8 treatments, and 28% of patients demonstrated more than 75% clinical improvement. Striae in thicker skin regions (e.g., buttocks/thighs) showed comparable clinical improvement than those in thinner skin areas (e.g., breasts) and did not require additional treatment sessions. Side effects were limited to transient erythema in all skin phototypes. No infections or dyspigmentation were observed. CONCLUSION: The clinical results obtained in this study support the safe and effective treatment of striae distensae with microneedling in light and dark skin tones in various body locations. Standardization of treatment protocols are anticipated with further (ongoing) studies.

An Observational Study of the Safety and Efficacy of Tissue Stabilized-Guided Subcision.

BACKGROUND: Cellulite is a common female cosmetic concern for which there are few treatment options with long-term effectiveness data. The aim of this multisite prospective registry study was to collect observational data on the real-life clinical use of a tissue stabilized-guided subcision (TS-GS) system for long-term improvement of cellulite appearance. METHODS: Fifty-three subjects were enrolled and received a single treatment using the TS-GS system. Physicians treated the subjects according to their standard of care. Global Aesthetic Improvement Scale (GAIS) was completed by the patient and clinician assessing overall aesthetic improvement after 180 days. Treatment parameters, pain scores, quality of life data, and expected treatment effects and adverse events were also recorded throughout the study. RESULTS: The patient and physician GAIS scores at Day 180 revealed an overall improvement in 91% and 96% of patients, respectively. Quality of life and self-confidence scores also improved through 180 days. No serious adverse events were reported. Expected treatment effects were similar to those reported in the pivotal trial supporting FDA clearance. CONCLUSION: This study demonstrated significant improvement in the appearance of cellulite after a single treatment session in patients with moderate-to-severe cellulite. These results are consistent with the previously published the pivotal study data.

Microneedling: A Review and Practical Guide.

BACKGROUND: Microneedling is a relatively new treatment option in dermatology and has been touted for a broad range of applications including skin rejuvenation, acne scarring, rhytides, surgical scars, dyschromia, melasma, enlarged pores, and transdermal drug delivery. The significant increase in minimally invasive procedures that has been reported over the past several years suggest that microneedling may occupy a specific niche for patients who desire measurable clinical results from treatments with little to no recovery. OBJECTIVE: To review the published medical literature relating to microneedling in dermatology and provide a practical guide for its use in clinical practice. MATERIALS AND METHODS: A thorough literature search of microneedling in dermatology using PubMed was conducted, and all references pertaining to skin scarring and rejuvenation were reviewed. Based on the information presented in these publications and the authors' clinical experience, a microneedling technique is outlined for clinical practice. Pretreatment recommendations, intraoperative technique and treatment end points, and postoperative considerations are outlined. RESULTS: Microneedling produces substantial clinical improvement of scars, striae, and rhytides with expedient recovery and limited side effects. Controlled dermal wounding and stimulation of the wound healing cascade enhances collagen production and is likely responsible for the clinical results obtained. CONCLUSION: Microneedling is a safe, minimally invasive, and effective esthetic treatment for several different dermatologic conditions including acne and other scars, rhytides, and striae. Given its expedient post-treatment recovery, limited side effect profile, and significant clinical results, microneedling is a valuable alternative to more invasive procedures such as laser skin resurfacing and deep chemical peeling.

Treatment of Cosmetic Tattoos: A Review and Case Analysis.

BACKGROUND: Cosmetic tattoos such as eyeliner, brow liner, and lip liner have become increasingly popular in the United States and throughout the world. For a variety of reasons, patients frequently regret their tattoos and request their removal; however, removal is often complicated by the aesthetically sensitive location of these specialized tattoos and the fact that they often contain white metallic compounds that darken on pigment-specific laser irradiation. OBJECTIVE: To review the clinical use, effectiveness, and safety of an ablative laser technique for cosmetic tattoos. MATERIALS AND METHODS: A thorough literature review pertaining to laser treatment of cosmetic tattoos and a discussion of illustrative patient cases showcasing the successful use of ablative carbon dioxide (CO2) laser to treat cosmetic tattoos is presented. RESULTS: Cosmetic eyeliner and lip liner tattoos were significantly improved after CO2 laser vaporization. Side effects were limited to erythema, edema, and serosanguinous drainage. No infection, scarring, nor tattoo ink darkening was observed. CONCLUSION: Because ablative lasers do not target specific tattoo inks, they do not pose a risk of paradoxical tattoo ink darkening and, thus, can be applied successfully in the treatment of iron oxide- or titanium dioxide-containing cosmetic tattoos.

Safety and Efficacy of a 1550nm/1927nm Dual Wavelength Laser for the Treatment of Photodamaged Skin.

BACKGROUND: Fractional photothermolysis (FP) is a popular treatment option for photodamaged skin and addresses shortcomings of ablative skin resurfacing and nonablative dermal remodeling. Previous studies have demonstrated that FP using the 1550nm wavelength has led to improvement of ultrastructural changes and clinical effects associated with photodamaged skin in the deeper dermal structures, while treatment with the 1927nm wavelength has shown clinical effects in the superficial dermis. Both wavelengths produce precise microscopic treatment zones (MTZs) in the skin. The two wavelengths used in combination may optimize the delivery of fractional nonablative resurfacing intended for dermal and epidermal coagulation of photodamage skin.

OBJECTIVES: To evaluate the safety and efficacy of a 1550/1927 Laser System (Fraxel Dual, Solta), using both 1550nm and 1927nm wavelengths in combination for treatment of facial and non-facial photodamage.

METHODS: Prospective, multi-center, post-market study in subjects with clinically identifiable photodamage (N=35) (Fitzpatrick skin types I-IV). Both 1550nm and 1927nm wavelengths were used at each treatment visit. Investigator assessment of the affected area(s) occurred at one week, one month and 3 months after a series of up to four treatments. Severity of adverse events (AEs) were assessed using a 4-point scale (where 0=none and 3=marked). Assessments included erythema, edema, hyperkeratosis, hyper- and hypo-pigmentation, scarring, itchiness, dryness, and flaking. Severity of photoaging, fine and coarse wrinkling, mottled hyperpigmentation, sallowness, and tactile roughness at baseline was assessed using the same scale. Investigators and subjects assessed overall appearance of photodamage and pigmentation based on a 5-point quartile improvement scale at all follow-up visits (where 0=no improvement and 4=very significant improvement [76%-100%]).

RESULTS: There was a positive treatment effect at all study visits, with moderate improvement (average reduction in severity of 21%-43%) observed 3-months after final treatment. Greatest reduction in severity of other benefit areas was at the 3-month follow-up visit, with a 21% and 30% decrease in severity in fine wrinkling and tactile roughness. No AEs or serious AEs were reported. Pain sensation during treatment was tolerable. Anticipated moderate erythema (mean score 1.6±0.5) and mild edema (mean score 0.8±0.7) were transient and resolved within 7-10 days. Anticipated and transient mild dryness (52% of subjects) and flaking (30%) were reported at the 1-week follow-up. There were no incidences of hyperkeratosis, scarring, or itchiness.

CONCLUSION: Treatments using both wavelengths associated with the combined 1550/1927 Laser System were well tolerated with limited, transient anticipated side effects and no serious AEs. Clinical efficacy in the appearance of photodamage and pigmentation was greatest following a series of up to 3 treatments.

J Drugs Dermatol. 2018;17(1):41-46.

Delayed Onset Pain Associated With Cryolipolysis Treatment: A Retrospective Study With Treatment Recommendations.

BACKGROUND: Cryolipolysis has become a popular treatment for noninvasive destruction of unwanted subcutaneous fat. It is a generally well-tolerated treatment with mild transient side effects. Delayed posttreatment pain has been sporadically reported, but its incidence, etiology, and treatment have not been elucidated in a large series of patients. METHODS: A retrospective review of 125 patients who received 554 cryolipolysis procedures over a 1-year period was conducted. Demographic data were obtained to determine specific variables that influenced development of delayed posttreatment pain. RESULTS: Young women (mean age, 39 years) undergoing abdominal cryolipolysis were at greatest risk of experiencing delayed posttreatment pain. The pain was self-limited (duration, 3-11 days) and resolved completely without long-term sequelae. The number of treatment cycles did not impact the development of this side effect. CONCLUSION: Delayed posttreatment pain is a not uncommon adverse effect after cryolipolysis. Patients should be counseled on the possibility of its occurrence, and timely intervention should be instituted to reduce its impact.

A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown Lines.

BACKGROUND: IncobotulinumtoxinA and onabotulinumtoxinA are indicated for the temporary improvement in the appearance of glabellar frown lines (GFL). This is the first randomized direct comparator study to date, at the Food and Drug Administration-recommended dose of 20 units (U), for the treatment of GFL. OBJECTIVE: To investigate the dose equivalence of incobotulinumtoxinA (20 U) and onabotulinumtoxinA (20 U) for the treatment of moderate-to-severe GFL. MATERIALS AND METHODS: Prospective, randomized (1:1), double-blinded, parallel-group study in 250 females (18-50 years), employing a single treatment with incobotulinumtoxinA or onabotulinumtoxinA, followed by a 4-month observational period. RESULTS: At the primary efficacy endpoint (1 month after treatment), incobotulinumtoxinA was equivalent to onabotulinumtoxinA in the treatment of GFL at the 20 U dose within the prespecified ± 15% margin of equivalence. Efficacy remained similar between treatment groups through 4 months after treatment as assessed by the independent masked panel and the masked treating physicians. Patient satisfaction ratings were similar between groups and favorable (>90%) throughout. Both treatments were well tolerated. CONCLUSION: Equivalence was demonstrated at the primary endpoint between incobotulinumtoxinA and onabotulinumtoxinA in the treatment of GFL at the 20 U dose at 1 month. Similar efficacy and tolerability profiles were observed through 4 months after treatment.

Evolution of laser skin resurfacing: from scanning to fractional technology.

BACKGROUND: Laser skin resurfacing was popularized for photoaged and scarred skin 2 decades ago. Since then, several technologic advancements have led to a new generation of delivery systems that produce excellent clinical outcomes with reduced treatment risks and faster recovery times. OBJECTIVES: To review the evolution of laser skin resurfacing from pulsed and scanned infrared laser technology to the latest techniques of nonablative and ablative fractional photothermolysis. MATERIALS AND METHODS: All published literature regarding laser skin resurfacing was analyzed and collated. RESULTS: A comprehensive review of laser skin resurfacing was outlined and future developments in the field of fractionated laser skin treatment were introduced. CONCLUSION: Laser skin resurfacing has evolved such that excellent clinical outcomes in photodamaged and scarred skin are achieved with rapid wound healing. As newer devices are developed, the applications of this technology will have a dramatic effect on the delivery of medical and aesthetic dermatology.

Vascular skin lesions in children: a review of laser surgical and medical treatments.

Vascular anomalies are a common finding in children. Although most of these lesions are benign, they can be a severe cosmetic problem and cause structural and functional damage to nearby tissues. As a result, physicians are tasked with developing effective treatment options with superior safety profiles. Vascular anomalies may be divided into tumors and malformations. Vascular tumors, such as infantile hemangiomas, typically appear a few months after birth, whereas the majority of vascular malformations, such as port-wine stains, are present at birth. Although these lesions vary in appearance, etiology, and disease course, many are treated in a similar fashion. In this review, we focus on treatment modalities for some of the more-prevalent childhood vascular lesions, including port-wine stains, primary telangiectasias, infantile hemangiomas, pyogenic granulomas, and angiomas.

Laser earlobe revision.

BACKGROUND: Earlobe tears and disfigurement often result from prolonged pierced earring use and trauma. They are a common cosmetic complaint for which surgical reconstruction has often been advocated. MATERIALS AND METHODS: A series of 10 patients with earlobe tears or disfigurement treated using straight-line closure, carbon dioxide (CO2 ) laser ablation, or both are described. A succinct literature review of torn earlobe repair is provided. RESULTS: Successful repair with excellent cosmesis of torn and disfigured earlobes was obtained after straight-line surgical closure, CO2 laser ablation, or both. CONCLUSION: A minimally invasive earlobe repair technique that involves concomitant surgical closure and CO2 laser skin vaporization produces excellent cosmetic results for torn or disfigured earlobes.

Botulinum toxin in men: review of relevant anatomy and clinical trial data.

BACKGROUND: Botulinum toxin is widely used for facial aesthetics, and its use in men continues to increase. OBJECTIVE: To provide a review of pertinent male anatomic features and updated clinical information on the use of botulinum toxin in men. METHODS: A Medline search was performed for publications on sex differences in facial anatomy and on clinical studies examining the role of sex in botulinum toxin treatment. RESULTS: There are substantial facial anatomic differences between the sexes, with men having increased cranial size, unique cranial shape, greater skeletal muscle mass, higher density of facial blood vessels, and more-severe facial rhytides. A review of sex and botulinum toxin treatment identified 17 clinical studies with 5,646 total participants, of whom 629 (11.1%) were male. Only two studies accounted for sex in study design or subgroup analysis. Both studies found abobotulinumtoxinA to be less effective in men. An additional study examining onabotulinumtoxinA dosing in men found that higher doses than typically used in women were more efficacious. There were not more adverse events in male participants in any study. CONCLUSION: Despite sex differences in facial anatomy, the use of botulinum toxin in men is inadequately studied with regard to dosing, efficacy, and safety.

Rising concern over cosmetic tattoos.

BACKGROUND: A rise in popularity of cosmetic tattoos has led to an increase in adverse reactions. Due to more pressing concerns, the Food and Drug Administration (FDA) has not traditionally enforced its authority over tattoo inks. OBJECTIVE: To raise awareness of the dangers of cosmetic tattoos. MATERIALS AND METHODS: We reviewed FDA policies regarding tattoo ink, different ink components, adverse reactions, and various treatment options for cosmetic tattoo removal. RESULTS AND CONCLUSION: An increase in consumer complaints has prompted FDA investigation into tattoo inks and their safety. It is important that further complications be reported to the FDA to promote regulation of cosmetic tattoo inks.

Topical anesthetics for dermatologic procedures: a review.

BACKGROUND: Practitioners are increasingly using topical anesthetics to decrease the pain associated with superficial dermatologic, aesthetic, and laser procedures. Numerous lidocaine-containing products are available, but comprehensive reviews are lacking regarding their relative safety profiles and appropriate dermatologic uses. MATERIALS AND METHODS: A literature review of currently available topical anesthetics, their safety profiles, and dermatologic uses was conducted. RESULTS: Factors that should be considered to reduce the risk of side effects associated with the use of topical anesthetics include the amount of product used, body location, size of the surface area, and duration of product application. Many case reports document adverse outcomes associated with the use of compounded products that the Food and Drug Administration has not approved that have inappropriately high anesthetic concentrations and from the use of topical anesthetics on excessively large skin surface areas during laser treatments. CONCLUSIONS: Lidocaine-containing products play an integral role in cutaneous anesthesia by providing patient comfort with minimal side effects. Careful attention must be paid to the particular anatomic location, the total surface area covered, and the duration of anesthetic skin contact.

Noninvasive lifting of arm, thigh, and knee skin with transcutaneous intense focused ultrasound.

BACKGROUND: Transcutaneous intense focused ultrasound is a novel Food and Drug Administration-approved technology for noninvasive skin tightening of the face and neck. No studies have reported on its safety and effectiveness on nonfacial areas. MATERIALS AND METHODS: Eighteen paired areas (6 each) on the upper arms, medial thighs, and extensor knees were randomly treated with two different transducers (4.0 MHz, 4.5-mm focal depth and 7.0 MHz, 3.0-mm focal depth). One side was randomly assigned to receive a single pass (single plane) of microthermal coagulation zones over the involved area with the 4.0 MHz, 4.5-mm-depth transducer, and the contralateral side was assigned to receive consecutive single passes (dual plane) using both transducers (4.0 MHz, 4.5-mm depth followed by 7.0 MHz, 3.0-mm depth). Two independent masked assessors determined clinical improvement scores using comparative standardized photographs obtained at baseline and 3 and 6 months after treatment. Subjective assessments of clinical improvement and side effects of treatment were obtained. RESULTS: Global assessment scores revealed significant improvement in all treated areas, with the upper arms and knees demonstrating more skin lifting and tightening than the thighs. Areas receiving dual-plane treatment had slightly better clinical scores than those receiving single-plane treatment in all three sites. Clinical scores from single-plane and dual-plane treated areas continued to improve between 3 and 6 months after treatment. Side effects were mild and transient and included erythema, warmth, and skin tenderness. Rare focal bruising was noted in two patients on the upper arms that resolved within 7 days. No other side effects were reported or observed. CONCLUSIONS: Transcutaneous intense focused ultrasound can be safely and effectively used to improve the clinical appearance (texture and contour) of the upper arms, extensor knees, and medial thighs.

CO2 Laser Treatment of Multiple Oral Hamartomas in Cowden's Syndrome: A Review and Case Study.

Background: Cowden's syndrome is a genetic disorder characterized by multiple oral hamartomas and an increased risk of internal malignancy. These mucocutaneous lesions can be physically disfiguring and psychologically distressing. As a result, patients frequently seek treatment for their destruction. Removal of oral hamartomas is often a challenge due to their sensitive location and high risk of recurrence. Objective: To review the clinical use, effectiveness, and safety of a fractional ablative laser to treat multiple oral hamartomas in a patient with Cowden's syndrome. Materials and Methods: A thorough literature review pertaining to treatment of oral hamartomas and a discussion of an illustrative case showcasing successful lesional destruction with a fractional ablative carbon dioxide (CO2) laser in a 33-year-old man with Cowden's syndrome. Results: Multiple oral hamartomas were effectively removed with fractional CO2 laser vaporization. No infection, scarring, dermatitis, nor lesional recurrence were observed 6 months post-treatment. Conclusion: Fractional CO2 laser vaporization can be used effectively to treat multiple oral hamartomas associated with Cowden's syndrome.

Fractionated laser skin resurfacing treatment complications: a review.

BACKGROUND: Fractional photothermolysis represents a new modality of laser skin resurfacing that was developed to provide a successful clinical response while minimizing postoperative recovery and limiting treatment complications. OBJECTIVES: To review all of the reported complications that develop as a result of fractional ablative and nonablative laser skin resurfacing. METHODS: A literature review was based on a MEDLINE search (1998-2009) for English-language articles related to laser treatment complications and fractional skin resurfacing. Articles presenting the highest level of evidence and the most recent reports were preferentially selected. RESULTS: Complications with fractional laser skin resurfacing represent a full spectrum of severity and can be longlasting. In general, a greater likelihood of developing post-treatment complications is seen in sensitive cutaneous areas and in patients with intrinsically darker skin phototypes or predisposing medical risk factors. CONCLUSIONS: Although the overall rate of complications associated with fractional laser skin resurfacing is much lower than with traditional ablative techniques, recent reports suggest that serious complications can develop. An appreciation of all of the complications associated with fractional laser skin resurfacing is important, especially given that many of them can be potentially prevented. The authors have indicated no significant interest with commercial supporters.

Clinical efficacy of a novel sonic infusion system for periorbital rhytides.

Aging skin is a leading concern of most men and women seeking cosmetic dermatologic consultation. Various in-office procedures as well as topical at-home regimens, are generally prescribed to reduce the signs of aging, but relatively few provide immediate clinical benefit. A novel sonic infusion system that combines sonic micro-massage with an anti-aging serum was studied to determine its immediate effect on a wide range of patients with periocular rhytides. Clinical improvement of periocular rhytides was achieved after a single sonic infusion treatment (30 seconds/eye). Patients with more severe rhytides and those older than 40 years of age showed the best clinical results.

Dermatologic Laser Side Effects and Complications: Prevention and Management.

The evolution of modern laser and light-based systems has mirrored the demand for clinically effective treatments and the need for safer technologies with reduced postoperative recovery, side effects, and complications. With each new generation of lasers, more selective tissue destruction can be achieved with reduced unwanted sequelae. Patient selection and preparation, operator technique, and expeditious recognition and management of post-treatment side effects are paramount in avoiding complications and patient dissatisfaction. An overview of important variables to consider for dermatologic laser treatments are presented in order to provide a framework to reduce the severity and duration of possible post-treatment side effects and complications.

Microneedling of Scars: A Large Prospective Study with Long-Term Follow-Up.

BACKGROUND: In recent years, microneedling has been increasingly used to treat a number of dermatologic conditions, including scars. Although initial studies demonstrated improvement of (mostly) atrophic scars with microneedling, the number of patients evaluated was relatively small, and the devices and treatment protocols used and posttreatment follow-up varied widely. Through this prospective observational study, the results of microneedling on 120 patients with a variety of scars are described. METHODS: One hundred twenty consecutive patients (skin phototypes I through VI) with facial and nonfacial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of scars 1, 3, 6, and 12 months after treatment on a five-point scale. Side effects were monitored and tabulated. RESULTS: Patients received one to six consecutive monthly microneedling treatments. All scars improved at least 50 percent after an average of 2.5 treatments. Over 80 percent of patients had 50 to 75 percent improvement, and 65 percent of patients demonstrated over 75 percent improvement. No significant clinical differences were observed in treatment responses of facial scars versus nonfacial scars nor between responses of atrophic acne scars and traumatic or surgical scars. CONCLUSIONS: This study supports the use of microneedling for various facial and nonfacial scars across a broad range of skin phototypes with minimal risk of adverse effects. Further studies will help to establish standardized protocols to optimize treatment outcomes for different scar types. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.