Aesthetic Dermatology

The average physician fee for the most popular form of minimally invasive cosmetic surgery, injection of botulinum toxin type A, dropped 6.6% from 2008 to 2011, according to data from the American Society of Plastic Surgeons.

The average fees for the five most popular minimally invasive surgeries fell in that time period, with microdermabrasion (29.5%) and laser hair removal (21.5%) showing the largest drops. Soft-tissue filler injection had the smallest decrease, 1.1%, the ASPS data show.

There were an estimated 5.7 million botulinum toxin A injections performed in 2011, which was almost half of the 12.2 million minimally invasive procedures performed for the year. The next-most popular procedure was soft-tissue filler injection, which accounted for 1.9 million procedures, the ASPS reported.

Notes: Listed in order of popularity. 2011 estimates are based on data from a national database and survey responses from 1,266 dermatologists, ENTs, and plastic surgeons.

Source: American Society of Plastic Surgeons

The average physician fee for the most popular form of minimally invasive cosmetic surgery, injection of botulinum toxin type A, dropped 6.6% from 2008 to 2011, according to data from the American Society of Plastic Surgeons.

The average fees for the five most popular minimally invasive surgeries fell in that time period, with microdermabrasion (29.5%) and laser hair removal (21.5%) showing the largest drops. Soft-tissue filler injection had the smallest decrease, 1.1%, the ASPS data show.

There were an estimated 5.7 million botulinum toxin A injections performed in 2011, which was almost half of the 12.2 million minimally invasive procedures performed for the year. The next-most popular procedure was soft-tissue filler injection, which accounted for 1.9 million procedures, the ASPS reported.

Notes: Listed in order of popularity. 2011 estimates are based on data from a national database and survey responses from 1,266 dermatologists, ENTs, and plastic surgeons.

Source: American Society of Plastic Surgeons

The average physician fee for the most popular form of minimally invasive cosmetic surgery, injection of botulinum toxin type A, dropped 6.6% from 2008 to 2011, according to data from the American Society of Plastic Surgeons.

The average fees for the five most popular minimally invasive surgeries fell in that time period, with microdermabrasion (29.5%) and laser hair removal (21.5%) showing the largest drops. Soft-tissue filler injection had the smallest decrease, 1.1%, the ASPS data show.

There were an estimated 5.7 million botulinum toxin A injections performed in 2011, which was almost half of the 12.2 million minimally invasive procedures performed for the year. The next-most popular procedure was soft-tissue filler injection, which accounted for 1.9 million procedures, the ASPS reported.

Notes: Listed in order of popularity. 2011 estimates are based on data from a national database and survey responses from 1,266 dermatologists, ENTs, and plastic surgeons.

Source: American Society of Plastic Surgeons

WAIKOLOA, HAWAII – Topically applied botulinum toxin type A may no longer be a pipe dream, as it is now likely full speed ahead for proposed phase III trials of the agent.

The completed phase II program consisted of 11 clinical studies in which 553 patients had their lateral canthal lines treated with the investigational topical product known for now as RT001, under development by Revance Therapeutics. The results were highly impressive, according to Dr. Alastair Carruthers, a dermatologist at the University of British Columbia, Vancouver.

"Watch out for topical botulinum toxin. I think Revance is going to turn the neurotoxin market upside down," he predicted at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Revance has developed a proprietary platform that enables transcutaneous flux of large medicinal payloads. The company has reported successful proof-of-concept studies for topically delivered insulin, growth factors, and numerous other macromolecules with applications in fields ranging from cardiovascular disease to cancer. But it’s the topical botulinum toxin project that has captured Dr. Carruthers’ attention.

"Their technology enables you to get the neurotoxin across intact skin, which is something I never thought that we would see. But it really works," he said.

No significant adverse events occurred in the phase II studies. There was no evidence of diffusion of neurotoxin away from the target muscle, and no effect upon the cranial nerves, he said. Laboratory monitoring and ECGs did not yield any evidence of systemic exposure.

The median duration of therapeutic effect was 113 days. The response rate was up to 89% based upon a stringent composite end point requiring a 2-point improvement as assessed independently by investigator and patient, he said.

The key to this technology is a synthetic peptide carrier which contains protein transduction domains and a backbone core that attaches to the neurotoxin molecule. This peptide carrier can be set to achieve different depths of penetration.

The proposed commercial product that will undergo phase III testing entails mixing the viscous topical gel in a one-step applicator, which is then used in treating the lateral canthal lines. The mixing and application takes only a couple of minutes. The gel is left on for perhaps 30 minutes – the optimal time is yet to be determined – and then removed with a proprietary cleanser.

Dr. Carruthers said that as many know, increasing competition has arrived among the manufacturers of the three Food and Drug Administration–approved injectable botulinum toxin type A products.

"I doubt that the battle, such as it is, will be fought on intellectual, scientific issues. I think it will be fought based upon cost, marketing, and other intangibles," he predicted.

Brand loyalty, company sponsorship of medical education, appeals to nationalism – one manufacturer is U.S.-based, the others German and French – these are the sorts of issues he expects to see brought forth.

That’s because the things that really matter to clinicians, such as onset of therapeutic effect, its spread, duration, and side effects, are all a function of dose – and there is no agreement as to what the comparable dose is between the various commercial preparations. Despite manufacturers’ claims, it’s not possible to detect small differences in effectiveness, immunogenicity, or other end points without doing studies that would require enormous numbers of patients, according to Dr. Carruthers.

He advised that given the uncertainty regarding dosing comparability, the best practice is to have only one botulinum toxin type A product in the office. This avoids the thorny issue of trying to use comparably effective dilutions.

In a separate presentation at the annual meeting of the American Society for Dermatologic Surgery, Dr. Gary D. Monheit, a dermatologist in private practice in Birmingham, Ala., agreed that the topical botulinum toxin could be practice changing.

He said that RT001 is best for superficial musculature such as crows’ feet, and possibly in the future for perioral and forehead wrinkles.

The investigational product affects pore size and helps smooth the skin, he said. And since the product is mostly absorbed in the superficial musculature, it could eventually be used on the eyelids and lips for superficial wrinkles and to brighten up dull skin.

Dr. Carruthers reported that he has no financial relationship with Revance. He is a consultant to, and paid investigator for, Allergan and Merz, which market Botox (onabotulinumtoxinA) and Xeomin (incobotulinumtoxinA), respectively.

Dr. Monheit is a consultant and clinical investigator for Revance.

SDEF and this news organization are owned by Elsevier.

Naseem Miller was a contributing writer.

WAIKOLOA, HAWAII – Topically applied botulinum toxin type A may no longer be a pipe dream, as it is now likely full speed ahead for proposed phase III trials of the agent.

The completed phase II program consisted of 11 clinical studies in which 553 patients had their lateral canthal lines treated with the investigational topical product known for now as RT001, under development by Revance Therapeutics. The results were highly impressive, according to Dr. Alastair Carruthers, a dermatologist at the University of British Columbia, Vancouver.

"Watch out for topical botulinum toxin. I think Revance is going to turn the neurotoxin market upside down," he predicted at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Revance has developed a proprietary platform that enables transcutaneous flux of large medicinal payloads. The company has reported successful proof-of-concept studies for topically delivered insulin, growth factors, and numerous other macromolecules with applications in fields ranging from cardiovascular disease to cancer. But it’s the topical botulinum toxin project that has captured Dr. Carruthers’ attention.

"Their technology enables you to get the neurotoxin across intact skin, which is something I never thought that we would see. But it really works," he said.

No significant adverse events occurred in the phase II studies. There was no evidence of diffusion of neurotoxin away from the target muscle, and no effect upon the cranial nerves, he said. Laboratory monitoring and ECGs did not yield any evidence of systemic exposure.

The median duration of therapeutic effect was 113 days. The response rate was up to 89% based upon a stringent composite end point requiring a 2-point improvement as assessed independently by investigator and patient, he said.

The key to this technology is a synthetic peptide carrier which contains protein transduction domains and a backbone core that attaches to the neurotoxin molecule. This peptide carrier can be set to achieve different depths of penetration.

The proposed commercial product that will undergo phase III testing entails mixing the viscous topical gel in a one-step applicator, which is then used in treating the lateral canthal lines. The mixing and application takes only a couple of minutes. The gel is left on for perhaps 30 minutes – the optimal time is yet to be determined – and then removed with a proprietary cleanser.

Dr. Carruthers said that as many know, increasing competition has arrived among the manufacturers of the three Food and Drug Administration–approved injectable botulinum toxin type A products.

"I doubt that the battle, such as it is, will be fought on intellectual, scientific issues. I think it will be fought based upon cost, marketing, and other intangibles," he predicted.

Brand loyalty, company sponsorship of medical education, appeals to nationalism – one manufacturer is U.S.-based, the others German and French – these are the sorts of issues he expects to see brought forth.

That’s because the things that really matter to clinicians, such as onset of therapeutic effect, its spread, duration, and side effects, are all a function of dose – and there is no agreement as to what the comparable dose is between the various commercial preparations. Despite manufacturers’ claims, it’s not possible to detect small differences in effectiveness, immunogenicity, or other end points without doing studies that would require enormous numbers of patients, according to Dr. Carruthers.

He advised that given the uncertainty regarding dosing comparability, the best practice is to have only one botulinum toxin type A product in the office. This avoids the thorny issue of trying to use comparably effective dilutions.

In a separate presentation at the annual meeting of the American Society for Dermatologic Surgery, Dr. Gary D. Monheit, a dermatologist in private practice in Birmingham, Ala., agreed that the topical botulinum toxin could be practice changing.

He said that RT001 is best for superficial musculature such as crows’ feet, and possibly in the future for perioral and forehead wrinkles.

The investigational product affects pore size and helps smooth the skin, he said. And since the product is mostly absorbed in the superficial musculature, it could eventually be used on the eyelids and lips for superficial wrinkles and to brighten up dull skin.

Dr. Carruthers reported that he has no financial relationship with Revance. He is a consultant to, and paid investigator for, Allergan and Merz, which market Botox (onabotulinumtoxinA) and Xeomin (incobotulinumtoxinA), respectively.

Dr. Monheit is a consultant and clinical investigator for Revance.

SDEF and this news organization are owned by Elsevier.

Naseem Miller was a contributing writer.

WAIKOLOA, HAWAII – Topically applied botulinum toxin type A may no longer be a pipe dream, as it is now likely full speed ahead for proposed phase III trials of the agent.

The completed phase II program consisted of 11 clinical studies in which 553 patients had their lateral canthal lines treated with the investigational topical product known for now as RT001, under development by Revance Therapeutics. The results were highly impressive, according to Dr. Alastair Carruthers, a dermatologist at the University of British Columbia, Vancouver.

"Watch out for topical botulinum toxin. I think Revance is going to turn the neurotoxin market upside down," he predicted at the Hawaii Dermatology Seminar, sponsored by Skin Disease Education Foundation (SDEF).

Revance has developed a proprietary platform that enables transcutaneous flux of large medicinal payloads. The company has reported successful proof-of-concept studies for topically delivered insulin, growth factors, and numerous other macromolecules with applications in fields ranging from cardiovascular disease to cancer. But it’s the topical botulinum toxin project that has captured Dr. Carruthers’ attention.

"Their technology enables you to get the neurotoxin across intact skin, which is something I never thought that we would see. But it really works," he said.

No significant adverse events occurred in the phase II studies. There was no evidence of diffusion of neurotoxin away from the target muscle, and no effect upon the cranial nerves, he said. Laboratory monitoring and ECGs did not yield any evidence of systemic exposure.

The median duration of therapeutic effect was 113 days. The response rate was up to 89% based upon a stringent composite end point requiring a 2-point improvement as assessed independently by investigator and patient, he said.

The key to this technology is a synthetic peptide carrier which contains protein transduction domains and a backbone core that attaches to the neurotoxin molecule. This peptide carrier can be set to achieve different depths of penetration.

The proposed commercial product that will undergo phase III testing entails mixing the viscous topical gel in a one-step applicator, which is then used in treating the lateral canthal lines. The mixing and application takes only a couple of minutes. The gel is left on for perhaps 30 minutes – the optimal time is yet to be determined – and then removed with a proprietary cleanser.

Dr. Carruthers said that as many know, increasing competition has arrived among the manufacturers of the three Food and Drug Administration–approved injectable botulinum toxin type A products.

"I doubt that the battle, such as it is, will be fought on intellectual, scientific issues. I think it will be fought based upon cost, marketing, and other intangibles," he predicted.

Brand loyalty, company sponsorship of medical education, appeals to nationalism – one manufacturer is U.S.-based, the others German and French – these are the sorts of issues he expects to see brought forth.

That’s because the things that really matter to clinicians, such as onset of therapeutic effect, its spread, duration, and side effects, are all a function of dose – and there is no agreement as to what the comparable dose is between the various commercial preparations. Despite manufacturers’ claims, it’s not possible to detect small differences in effectiveness, immunogenicity, or other end points without doing studies that would require enormous numbers of patients, according to Dr. Carruthers.

He advised that given the uncertainty regarding dosing comparability, the best practice is to have only one botulinum toxin type A product in the office. This avoids the thorny issue of trying to use comparably effective dilutions.

In a separate presentation at the annual meeting of the American Society for Dermatologic Surgery, Dr. Gary D. Monheit, a dermatologist in private practice in Birmingham, Ala., agreed that the topical botulinum toxin could be practice changing.

He said that RT001 is best for superficial musculature such as crows’ feet, and possibly in the future for perioral and forehead wrinkles.

The investigational product affects pore size and helps smooth the skin, he said. And since the product is mostly absorbed in the superficial musculature, it could eventually be used on the eyelids and lips for superficial wrinkles and to brighten up dull skin.

Dr. Carruthers reported that he has no financial relationship with Revance. He is a consultant to, and paid investigator for, Allergan and Merz, which market Botox (onabotulinumtoxinA) and Xeomin (incobotulinumtoxinA), respectively.

Dr. Monheit is a consultant and clinical investigator for Revance.

SDEF and this news organization are owned by Elsevier.

Naseem Miller was a contributing writer.

SAN DIEGO – Expect botanicals to play an increasing role in the development of cosmeceuticals to treat melasma, Dr. Zoe D. Draelos said at the annual meeting of the American Academy of Dermatology.

"Combinations of kojic acid, emblica, and glycolic acid are now available in the cosmeceutical market," said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C. "This combination uses several mechanisms of pigment lightening, and clinical results are pretty much on par with hydroquinone."

Courtesy Wikimedia Commons/L.Shyamal/Create Commons License

Perhaps the most effective pigment-lightening agent in the over-the-counter market, she said, is kojic acid, a hydrophilic fungal derivative evolved from Acetobacter, Aspergillus, and Penicillium. Obtained from mushrooms, it inhibits tyrosinase by binding to copper. "Kojic acid is thought to be the most effective active [agent] behind hydroquinone," said Dr. Draelos, who is also a consulting professor of dermatology at Duke University in Durham, N.C.

Licorice extracts are also widely used for the treatment of melasma, particularly the licorice-derived flavonoids liquiritin and isoquercetin. "Glabridin is the most commonly used substance," Dr. Draelos said. "It is commonly combined with kojic acid and other active agents in order to create a sort of cocktail to multidimensionally inhibit pigment production."

Sometimes kojic acid and licorice extracts are combined with arbutin, which is obtained from the bearberry plant. "Interestingly enough, arbutin is very similar to glycosylated hydroquinone, and it has been used in Indian tribal medicine," she said. The most active form is deoxyarbutin, which is synthetic, inhibits tyrosinase, and has no cytotoxicity.

Soy, which interferes with melanosome transfer, is another natural substance that is being used to treat melasma. Fresh soy milk contains soybean trypsin inhibitor (STI), a polypeptide that decreases protease-activated receptor-2, a protein that is important in the regulation of pigmentation. STI reduces keratinocytes and decreases pigmentation.

The newcomer for the treatment of melasma is emblica, also known as Indian gooseberry. This substance is high in vitamin C and tannins, but also contains flavonoids, kaempferol, ellagic acid, and gallic acid. "It is thought that the tannins contained within emblica inhibit melanogenesis in human melanocyte cultures," Dr. Draelos said. "It is also a potent antioxidant."

She concluded her presentation by noting that although melasma is an important dermatologic need, "the depth of pigment is key to treatment success. Sunscreens, pharmaceuticals, cosmeceuticals, and surgical treatments may be used individually or in combination to treat melasma."

Dr. Draelos disclosed that she has received research consulting funds from Beiersdorf, L’Oréal, Neocutis, Neutrogena, Nu Skin, Procter & Gamble, and Syneron.

SAN DIEGO – Expect botanicals to play an increasing role in the development of cosmeceuticals to treat melasma, Dr. Zoe D. Draelos said at the annual meeting of the American Academy of Dermatology.

"Combinations of kojic acid, emblica, and glycolic acid are now available in the cosmeceutical market," said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C. "This combination uses several mechanisms of pigment lightening, and clinical results are pretty much on par with hydroquinone."

Courtesy Wikimedia Commons/L.Shyamal/Create Commons License

Perhaps the most effective pigment-lightening agent in the over-the-counter market, she said, is kojic acid, a hydrophilic fungal derivative evolved from Acetobacter, Aspergillus, and Penicillium. Obtained from mushrooms, it inhibits tyrosinase by binding to copper. "Kojic acid is thought to be the most effective active [agent] behind hydroquinone," said Dr. Draelos, who is also a consulting professor of dermatology at Duke University in Durham, N.C.

Licorice extracts are also widely used for the treatment of melasma, particularly the licorice-derived flavonoids liquiritin and isoquercetin. "Glabridin is the most commonly used substance," Dr. Draelos said. "It is commonly combined with kojic acid and other active agents in order to create a sort of cocktail to multidimensionally inhibit pigment production."

Sometimes kojic acid and licorice extracts are combined with arbutin, which is obtained from the bearberry plant. "Interestingly enough, arbutin is very similar to glycosylated hydroquinone, and it has been used in Indian tribal medicine," she said. The most active form is deoxyarbutin, which is synthetic, inhibits tyrosinase, and has no cytotoxicity.

Soy, which interferes with melanosome transfer, is another natural substance that is being used to treat melasma. Fresh soy milk contains soybean trypsin inhibitor (STI), a polypeptide that decreases protease-activated receptor-2, a protein that is important in the regulation of pigmentation. STI reduces keratinocytes and decreases pigmentation.

The newcomer for the treatment of melasma is emblica, also known as Indian gooseberry. This substance is high in vitamin C and tannins, but also contains flavonoids, kaempferol, ellagic acid, and gallic acid. "It is thought that the tannins contained within emblica inhibit melanogenesis in human melanocyte cultures," Dr. Draelos said. "It is also a potent antioxidant."

She concluded her presentation by noting that although melasma is an important dermatologic need, "the depth of pigment is key to treatment success. Sunscreens, pharmaceuticals, cosmeceuticals, and surgical treatments may be used individually or in combination to treat melasma."

Dr. Draelos disclosed that she has received research consulting funds from Beiersdorf, L’Oréal, Neocutis, Neutrogena, Nu Skin, Procter & Gamble, and Syneron.

SAN DIEGO – Expect botanicals to play an increasing role in the development of cosmeceuticals to treat melasma, Dr. Zoe D. Draelos said at the annual meeting of the American Academy of Dermatology.

"Combinations of kojic acid, emblica, and glycolic acid are now available in the cosmeceutical market," said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C. "This combination uses several mechanisms of pigment lightening, and clinical results are pretty much on par with hydroquinone."

Courtesy Wikimedia Commons/L.Shyamal/Create Commons License

Perhaps the most effective pigment-lightening agent in the over-the-counter market, she said, is kojic acid, a hydrophilic fungal derivative evolved from Acetobacter, Aspergillus, and Penicillium. Obtained from mushrooms, it inhibits tyrosinase by binding to copper. "Kojic acid is thought to be the most effective active [agent] behind hydroquinone," said Dr. Draelos, who is also a consulting professor of dermatology at Duke University in Durham, N.C.

Licorice extracts are also widely used for the treatment of melasma, particularly the licorice-derived flavonoids liquiritin and isoquercetin. "Glabridin is the most commonly used substance," Dr. Draelos said. "It is commonly combined with kojic acid and other active agents in order to create a sort of cocktail to multidimensionally inhibit pigment production."

Sometimes kojic acid and licorice extracts are combined with arbutin, which is obtained from the bearberry plant. "Interestingly enough, arbutin is very similar to glycosylated hydroquinone, and it has been used in Indian tribal medicine," she said. The most active form is deoxyarbutin, which is synthetic, inhibits tyrosinase, and has no cytotoxicity.

Soy, which interferes with melanosome transfer, is another natural substance that is being used to treat melasma. Fresh soy milk contains soybean trypsin inhibitor (STI), a polypeptide that decreases protease-activated receptor-2, a protein that is important in the regulation of pigmentation. STI reduces keratinocytes and decreases pigmentation.

The newcomer for the treatment of melasma is emblica, also known as Indian gooseberry. This substance is high in vitamin C and tannins, but also contains flavonoids, kaempferol, ellagic acid, and gallic acid. "It is thought that the tannins contained within emblica inhibit melanogenesis in human melanocyte cultures," Dr. Draelos said. "It is also a potent antioxidant."

She concluded her presentation by noting that although melasma is an important dermatologic need, "the depth of pigment is key to treatment success. Sunscreens, pharmaceuticals, cosmeceuticals, and surgical treatments may be used individually or in combination to treat melasma."

Dr. Draelos disclosed that she has received research consulting funds from Beiersdorf, L’Oréal, Neocutis, Neutrogena, Nu Skin, Procter & Gamble, and Syneron.

A reader recently wrote to us with the following question:

A certain ad for a skin care line for darker tones claimed that black skin contains "more" collagen. I try to explain to my clients that skin is skin, with some containing a richer concentration of melanin than others, but this seems too simplistic. Am I wrong? How should I answer?

Answer:

You are right that the answers to these questions are difficult and not completely clear. Differences in melanin content and dispersion, accounting for the difference we see in skin color, are well known and easy to demonstrate.

Other differences among skin in different ethnic groups have been studied but are not as easy to explain. While the data is limited, there are more and more studies showing that some differences in skin architecture and physiology among ethnic groups do exist.

These early studies have suggested that the thickness of the skin is the same in light and dark skin, specifically in the epidermis. Darker skin types, however, may have more cornified cell layers and greater lipid content compared to white stratum corneum.

Another study showed statistically significant differences in ceramide and cholesterol ratios for different ethnicities, with Asians having the highest ratio, white skin intermediate, and black skin the lowest (Br. J. Dermatol. 2010;163:1169-73).

With regards to the dermis, darker skin has been found to have more and larger fibroblasts, smaller collagen fiber bundles, and more macrophages than white skin. This may have implications in the development of keloid formation that we sometimes see an increased incidence of in darker skin.

Other differences are summarized in the following tables:

Objective Differences in Skin Structure and Physiology Based on Race (Semin. Cut. Med. Surg. 2009;28:115-2)

^{* Skin elastic recovery/extensibility, skin microflora, and pore size were labeled as ‘insufficient evidence for’ racial differences rather than 'inconclusive' because only two studies or less examined these variables}

^{** Ethnic differences in the structural properties of facial skin. (J. Dermatol. Sci. 2009;53135-9)}

Therapeutic Implications of Key Biologic Differences Between Races

^{Ethnic Differences in Skin Properties. Textbook of Cosmetic Dermatology, 4th edition. 2010, p. 395-404}

The bottom line is that differences in ethnic groups do exist, and research is still being done to elucidate what these differences are.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to sknews@elsevier.com.

A reader recently wrote to us with the following question:

A certain ad for a skin care line for darker tones claimed that black skin contains "more" collagen. I try to explain to my clients that skin is skin, with some containing a richer concentration of melanin than others, but this seems too simplistic. Am I wrong? How should I answer?

Answer:

You are right that the answers to these questions are difficult and not completely clear. Differences in melanin content and dispersion, accounting for the difference we see in skin color, are well known and easy to demonstrate.

Other differences among skin in different ethnic groups have been studied but are not as easy to explain. While the data is limited, there are more and more studies showing that some differences in skin architecture and physiology among ethnic groups do exist.

These early studies have suggested that the thickness of the skin is the same in light and dark skin, specifically in the epidermis. Darker skin types, however, may have more cornified cell layers and greater lipid content compared to white stratum corneum.

Another study showed statistically significant differences in ceramide and cholesterol ratios for different ethnicities, with Asians having the highest ratio, white skin intermediate, and black skin the lowest (Br. J. Dermatol. 2010;163:1169-73).

With regards to the dermis, darker skin has been found to have more and larger fibroblasts, smaller collagen fiber bundles, and more macrophages than white skin. This may have implications in the development of keloid formation that we sometimes see an increased incidence of in darker skin.

Other differences are summarized in the following tables:

Objective Differences in Skin Structure and Physiology Based on Race (Semin. Cut. Med. Surg. 2009;28:115-2)

^{* Skin elastic recovery/extensibility, skin microflora, and pore size were labeled as ‘insufficient evidence for’ racial differences rather than 'inconclusive' because only two studies or less examined these variables}

^{** Ethnic differences in the structural properties of facial skin. (J. Dermatol. Sci. 2009;53135-9)}

Therapeutic Implications of Key Biologic Differences Between Races

^{Ethnic Differences in Skin Properties. Textbook of Cosmetic Dermatology, 4th edition. 2010, p. 395-404}

The bottom line is that differences in ethnic groups do exist, and research is still being done to elucidate what these differences are.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to sknews@elsevier.com.

A reader recently wrote to us with the following question:

A certain ad for a skin care line for darker tones claimed that black skin contains "more" collagen. I try to explain to my clients that skin is skin, with some containing a richer concentration of melanin than others, but this seems too simplistic. Am I wrong? How should I answer?

Answer:

You are right that the answers to these questions are difficult and not completely clear. Differences in melanin content and dispersion, accounting for the difference we see in skin color, are well known and easy to demonstrate.

Other differences among skin in different ethnic groups have been studied but are not as easy to explain. While the data is limited, there are more and more studies showing that some differences in skin architecture and physiology among ethnic groups do exist.

These early studies have suggested that the thickness of the skin is the same in light and dark skin, specifically in the epidermis. Darker skin types, however, may have more cornified cell layers and greater lipid content compared to white stratum corneum.

Another study showed statistically significant differences in ceramide and cholesterol ratios for different ethnicities, with Asians having the highest ratio, white skin intermediate, and black skin the lowest (Br. J. Dermatol. 2010;163:1169-73).

With regards to the dermis, darker skin has been found to have more and larger fibroblasts, smaller collagen fiber bundles, and more macrophages than white skin. This may have implications in the development of keloid formation that we sometimes see an increased incidence of in darker skin.

Other differences are summarized in the following tables:

Objective Differences in Skin Structure and Physiology Based on Race (Semin. Cut. Med. Surg. 2009;28:115-2)

^{* Skin elastic recovery/extensibility, skin microflora, and pore size were labeled as ‘insufficient evidence for’ racial differences rather than 'inconclusive' because only two studies or less examined these variables}

^{** Ethnic differences in the structural properties of facial skin. (J. Dermatol. Sci. 2009;53135-9)}

Therapeutic Implications of Key Biologic Differences Between Races

^{Ethnic Differences in Skin Properties. Textbook of Cosmetic Dermatology, 4th edition. 2010, p. 395-404}

The bottom line is that differences in ethnic groups do exist, and research is still being done to elucidate what these differences are.

- Naissan Wesley, M.D.

Do you have questions about treating patients with darker skin? If so, send them to sknews@elsevier.com.

KISSIMMEE, FLA. – Indocyanine green-augmented diode laser treatment appears promising for the treatment of both port wine stains and telangiectatic leg veins, preliminary data have shown.

This novel treatment involves an off-label use of the water-soluble indocyanine green fluorescent dye commonly used in medical diagnostics and approved by the Food and Drug Administration for determining cardiac output, hepatic function, and liver blood flow, and for ophthalmic angiography. Indocyanine green has a peak spectral absorption of 800 nm.

Port Wine Stains

A randomized, controlled pilot study compared indocyanine green-augmented diode laser (ICG+DL) treatment with standard flashlamp-pumped pulsed dye laser (FPDL) treatment in split-face fashion in 31 patients with port wine stains. After one treatment, two blinded investigators rated ICG+DL treatment as slightly, though not significantly, better than FPDL with respect to clearance rates and cosmetic appearance at 12 weeks’ follow-up (Br. J. Dermatol. 2012[doi:10.1111/j.1365-2133.2012.10950.x]). The patients rated the ICG+DL treatment as significantly superior to FPDL on these measures, Dr. Philipp Babilas reported at the annual meeting of the American Society for Laser Medicine and Surgery.

ICG+DL was applied at 810 nm with a fluence of 20-50 J/cm², a spot size of 7 mm, a pulse duration of 10-25 milliseconds, and an ICG concentration of 2 mg/kg of body weight; FPDL was applied at 585 nm with a fluence of 6 J/cm² and a pulse duration of 0.45 milliseconds, he said noting that the treatments were well tolerated.

Complete clearance of port wine stains is rarely achieved, largely because of the resistance of small blood vessels to laser irradiation. Prior studies suggested that the use of ICG with diode laser treatment could overcome this resistance, but in this study, histology revealed that the approach provided photocoagulation only of blood vessels larger than 20 mcm in diameter with collateral damage of surrounding dermal tissue, said Dr. Babilas of University Hospital Regensburg (Germany).

The results were nonetheless intriguing, he said, noting that histology also showed that there was no epidermal damage at 1 week and that complete remodeling of dermal tissue had occurred by 3 months.

Many smaller blood vessels replaced the larger blood vessels, which could be one reason the treatment was not as effective as expected, he said.

The findings, including the patient assessments of outcomes, suggest ICG+DL represents a promising treatment modality for port wine stains – a treatment that may prove even more effective as laser parameters and ICG concentrations undergo further study and optimization. Such studies, including one that is evaluating an increased concentration of indocyanine green, are underway in an effort to enhance results, he added.

The search for improved treatments for port wine stains is important given that available treatments typically provide only partial clearing, that about 20% of cases are resistant to FPDL treatment, and that port wine stains can be associated with significant adverse psychological effects, he said.

Leg Veins

In a separate proof-of-concept study, Dr. Babilas and his colleagues also evaluated ICG+DL for telangiectatic leg veins, which, like port wine stains, are rarely completely cleared.

The treatment was evaluated in 15 women with skin types II or III and telangiectatic leg veins of 0.25-3 mm in diameter. After intravenous administration of ICG, diode laser pulses were applied as a single treatment. The treatment was safe, with no persistent side effects, Dr. Annette Klein, also of University Hospital of Regensburg, reported.

ICG+DL in this study was applied at 808 nm, with a fluence of 50-110 J/cm² and an ICG concentration of 2 mg/kg of body weight (Lasers Surg. Med. 2012[doi:10.1002/lsm.22022]).

Vessel clearance was dose-dependent, with "good" (40%-50%) vessel clearance in those receiving a radiant exposure of 100-110 J/cm² and "excellent" (greater than 50%) clearance when double pulses of the diode laser were used, Dr. Klein said, noting that vessel clearance was rated only as "poor" or "moderate" (only up to 25%) with pulsed dye laser, which was used in this study as a reference treatment.

"We conclude that ICG-augmented diode laser therapy is a safe and effective new therapy option for the treatment of spider leg veins, and double pulses improved our results," she said, noting that follow-up studies to identify the optimal ICG concentration and laser parameters are underway.

Neither Dr. Babilas nor Dr. Klein reported any relevant financial disclosures.

KISSIMMEE, FLA. – Indocyanine green-augmented diode laser treatment appears promising for the treatment of both port wine stains and telangiectatic leg veins, preliminary data have shown.

This novel treatment involves an off-label use of the water-soluble indocyanine green fluorescent dye commonly used in medical diagnostics and approved by the Food and Drug Administration for determining cardiac output, hepatic function, and liver blood flow, and for ophthalmic angiography. Indocyanine green has a peak spectral absorption of 800 nm.

Port Wine Stains

A randomized, controlled pilot study compared indocyanine green-augmented diode laser (ICG+DL) treatment with standard flashlamp-pumped pulsed dye laser (FPDL) treatment in split-face fashion in 31 patients with port wine stains. After one treatment, two blinded investigators rated ICG+DL treatment as slightly, though not significantly, better than FPDL with respect to clearance rates and cosmetic appearance at 12 weeks’ follow-up (Br. J. Dermatol. 2012[doi:10.1111/j.1365-2133.2012.10950.x]). The patients rated the ICG+DL treatment as significantly superior to FPDL on these measures, Dr. Philipp Babilas reported at the annual meeting of the American Society for Laser Medicine and Surgery.

ICG+DL was applied at 810 nm with a fluence of 20-50 J/cm², a spot size of 7 mm, a pulse duration of 10-25 milliseconds, and an ICG concentration of 2 mg/kg of body weight; FPDL was applied at 585 nm with a fluence of 6 J/cm² and a pulse duration of 0.45 milliseconds, he said noting that the treatments were well tolerated.

Complete clearance of port wine stains is rarely achieved, largely because of the resistance of small blood vessels to laser irradiation. Prior studies suggested that the use of ICG with diode laser treatment could overcome this resistance, but in this study, histology revealed that the approach provided photocoagulation only of blood vessels larger than 20 mcm in diameter with collateral damage of surrounding dermal tissue, said Dr. Babilas of University Hospital Regensburg (Germany).

The results were nonetheless intriguing, he said, noting that histology also showed that there was no epidermal damage at 1 week and that complete remodeling of dermal tissue had occurred by 3 months.

Many smaller blood vessels replaced the larger blood vessels, which could be one reason the treatment was not as effective as expected, he said.

The findings, including the patient assessments of outcomes, suggest ICG+DL represents a promising treatment modality for port wine stains – a treatment that may prove even more effective as laser parameters and ICG concentrations undergo further study and optimization. Such studies, including one that is evaluating an increased concentration of indocyanine green, are underway in an effort to enhance results, he added.

The search for improved treatments for port wine stains is important given that available treatments typically provide only partial clearing, that about 20% of cases are resistant to FPDL treatment, and that port wine stains can be associated with significant adverse psychological effects, he said.

Leg Veins

In a separate proof-of-concept study, Dr. Babilas and his colleagues also evaluated ICG+DL for telangiectatic leg veins, which, like port wine stains, are rarely completely cleared.

The treatment was evaluated in 15 women with skin types II or III and telangiectatic leg veins of 0.25-3 mm in diameter. After intravenous administration of ICG, diode laser pulses were applied as a single treatment. The treatment was safe, with no persistent side effects, Dr. Annette Klein, also of University Hospital of Regensburg, reported.

ICG+DL in this study was applied at 808 nm, with a fluence of 50-110 J/cm² and an ICG concentration of 2 mg/kg of body weight (Lasers Surg. Med. 2012[doi:10.1002/lsm.22022]).

Vessel clearance was dose-dependent, with "good" (40%-50%) vessel clearance in those receiving a radiant exposure of 100-110 J/cm² and "excellent" (greater than 50%) clearance when double pulses of the diode laser were used, Dr. Klein said, noting that vessel clearance was rated only as "poor" or "moderate" (only up to 25%) with pulsed dye laser, which was used in this study as a reference treatment.

"We conclude that ICG-augmented diode laser therapy is a safe and effective new therapy option for the treatment of spider leg veins, and double pulses improved our results," she said, noting that follow-up studies to identify the optimal ICG concentration and laser parameters are underway.

Neither Dr. Babilas nor Dr. Klein reported any relevant financial disclosures.

KISSIMMEE, FLA. – Indocyanine green-augmented diode laser treatment appears promising for the treatment of both port wine stains and telangiectatic leg veins, preliminary data have shown.

This novel treatment involves an off-label use of the water-soluble indocyanine green fluorescent dye commonly used in medical diagnostics and approved by the Food and Drug Administration for determining cardiac output, hepatic function, and liver blood flow, and for ophthalmic angiography. Indocyanine green has a peak spectral absorption of 800 nm.

Port Wine Stains

A randomized, controlled pilot study compared indocyanine green-augmented diode laser (ICG+DL) treatment with standard flashlamp-pumped pulsed dye laser (FPDL) treatment in split-face fashion in 31 patients with port wine stains. After one treatment, two blinded investigators rated ICG+DL treatment as slightly, though not significantly, better than FPDL with respect to clearance rates and cosmetic appearance at 12 weeks’ follow-up (Br. J. Dermatol. 2012[doi:10.1111/j.1365-2133.2012.10950.x]). The patients rated the ICG+DL treatment as significantly superior to FPDL on these measures, Dr. Philipp Babilas reported at the annual meeting of the American Society for Laser Medicine and Surgery.

ICG+DL was applied at 810 nm with a fluence of 20-50 J/cm², a spot size of 7 mm, a pulse duration of 10-25 milliseconds, and an ICG concentration of 2 mg/kg of body weight; FPDL was applied at 585 nm with a fluence of 6 J/cm² and a pulse duration of 0.45 milliseconds, he said noting that the treatments were well tolerated.

Complete clearance of port wine stains is rarely achieved, largely because of the resistance of small blood vessels to laser irradiation. Prior studies suggested that the use of ICG with diode laser treatment could overcome this resistance, but in this study, histology revealed that the approach provided photocoagulation only of blood vessels larger than 20 mcm in diameter with collateral damage of surrounding dermal tissue, said Dr. Babilas of University Hospital Regensburg (Germany).

The results were nonetheless intriguing, he said, noting that histology also showed that there was no epidermal damage at 1 week and that complete remodeling of dermal tissue had occurred by 3 months.

Many smaller blood vessels replaced the larger blood vessels, which could be one reason the treatment was not as effective as expected, he said.

The findings, including the patient assessments of outcomes, suggest ICG+DL represents a promising treatment modality for port wine stains – a treatment that may prove even more effective as laser parameters and ICG concentrations undergo further study and optimization. Such studies, including one that is evaluating an increased concentration of indocyanine green, are underway in an effort to enhance results, he added.

The search for improved treatments for port wine stains is important given that available treatments typically provide only partial clearing, that about 20% of cases are resistant to FPDL treatment, and that port wine stains can be associated with significant adverse psychological effects, he said.

Leg Veins

In a separate proof-of-concept study, Dr. Babilas and his colleagues also evaluated ICG+DL for telangiectatic leg veins, which, like port wine stains, are rarely completely cleared.

The treatment was evaluated in 15 women with skin types II or III and telangiectatic leg veins of 0.25-3 mm in diameter. After intravenous administration of ICG, diode laser pulses were applied as a single treatment. The treatment was safe, with no persistent side effects, Dr. Annette Klein, also of University Hospital of Regensburg, reported.

ICG+DL in this study was applied at 808 nm, with a fluence of 50-110 J/cm² and an ICG concentration of 2 mg/kg of body weight (Lasers Surg. Med. 2012[doi:10.1002/lsm.22022]).

Vessel clearance was dose-dependent, with "good" (40%-50%) vessel clearance in those receiving a radiant exposure of 100-110 J/cm² and "excellent" (greater than 50%) clearance when double pulses of the diode laser were used, Dr. Klein said, noting that vessel clearance was rated only as "poor" or "moderate" (only up to 25%) with pulsed dye laser, which was used in this study as a reference treatment.

"We conclude that ICG-augmented diode laser therapy is a safe and effective new therapy option for the treatment of spider leg veins, and double pulses improved our results," she said, noting that follow-up studies to identify the optimal ICG concentration and laser parameters are underway.

Neither Dr. Babilas nor Dr. Klein reported any relevant financial disclosures.