Aesthetic Dermatology

WAIKOLOA, HAWAII – Cellulite therapy may finally be moving out of the dark ages of overhyped claims made on behalf of interventions of little or no value to an era of treatments that actually work.

And what appears to work, according to Dr. Michael S. Kaminer, are therapies that cut the fibrous septae tethering the dermis to deeper tissues.

"I think it’s likely that the vertical pull of the fibrous septae tends to pull down on the cellulite in the skin and causes the cellulite dimples," he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

The fibrous septae theory of the etiology of cellulite is relatively new. It has gained substantial credence as a result of encouraging clinical trial data showing long-term effectiveness for two devices targeting cellulite via severing fibrous septae: the Cellulaze 1,440-nm Nd:YAG laser and the Cabochon Aesthetics controlled subcision system for subdermal undermining, according to Dr. Kaminer, who is a managing partner at SkinCare Physicians, Chestnut Hill, Mass.

Cellulaze, developed by Cynosure, recently received Food and Drug Administration marketing approval for the treatment of cellulite. It is also approved across Europe for this indication. The Cabochon device for subcutaneous release of fibrous septae in patients with cellulite is still in clinical trials.

Dr. Kaminer said Americans spend an estimated $3 billion annually on ineffective treatments for cellulite. These therapies, many of which have been the beneficiaries of claims he termed "outrageous," aim to either reduce or redistribute subcutaneous fat or to thicken the skin surface through methods such as suction massage, which creates skin edema that temporarily camouflages the cellulite dimples. Among the myriad of available therapies are skin wraps, various injectables, and focused ultrasound. But the effect sizes are small and the results, if any, last for a matter of weeks.

"Until very recently, there was absolutely no reason to pay attention to cellulite except to counsel patients as to the fact that they shouldn’t waste their money, unless they feel good about wasting their money," Dr. Kaminer said.

The situation has changed dramatically with the emergence of fibrous septae as the prime therapeutic target. Cellulaze can be used for laser lipolysis; however, in addition, the handpiece for the cannula can be turned in such a way that the laser beam can be used like a saw to cut through the fibrous septae, with resultant long-term improvement in cellulite.

In U.S. clinical trials, the average increase in skin thickness following Cellulaze therapy was 23% at 1 month and 27% at 1 year. Skin elasticity improved over baseline by 32.5% at 1 month and 21% at 1 year. Sixty-eight percent of patients demonstrated significant improvement in cellulite based upon analysis of photographs, as did 65% when assessed by Vectra 3D surface imaging.

Patient self-evaluations rated the results as good to excellent at 1 month in 76% of cases. Physicians judged the results as good to excellent in 69% of cases. These results have held up at 1 year of follow-up, noted Dr. Kaminer, who also is with the dermatology departments of Yale University, New Haven, Conn.; Dartmouth College, Hanover, N.H.; and Brown University, Providence, R.I.

The downside of Cellulaze is that it is an invasive therapy that requires tumescent anesthesia. And given that the history of the field of cellulite therapy is one of hype far in excess of reality, Dr. Kaminer indicated that a healthy skepticism is appropriate.

"For me, I’m going to approach this with caution. I think Cellulaze is a great idea, and I think it gets to what many people believe is the root of cellulite. But I’d like to see it around for a little longer before we all jump on the bandwagon," he said.

The Cabochon system draws a small section of skin affected by cellulite into a handpiece so that a percutaneously inserted cutting tool can be utilized to cut the fibrous septae. Dr. Kaminer was an investigator in a two-site, 56-patient clinical trial with a 6- to 12-month follow-up.

In independent blinded physician review of before and after photos, 78% of patients were judged to have improved at least one full grade in severity at 6 months, such that, for example, those whose cellulite was rated severe at baseline were judged to have moderate or mild cellulite at follow-up.

At baseline, the average cellulite severity score was about 4.5 on a 0-6 scale. At 90 days, the average severity score had dropped to 3, and at 180 days to roughly 2.5. Ninety-four percent of patients were rated by independent physicians as having improved by at least 1 point on the 0-6 scale.

Of the 33 U.S. patients followed for 1 year, 87% felt their appearance was improved and 77% were satisfied with their treatment at all time points.

Seroma formation was an issue early on, until investigators realized the problem resulted from treating adjacent sites at the same depth. Seven of 31 patients treated in that manner had a seroma in excess of 2 cc at 1 month’s follow-up. But once operators began utilizing the device’s automated guidance system to vary the cutting depth at adjacent sites – for example, treating one area at a depth of 6 mm and an adjacent area at 10 mm of depth seromas were no longer a problem. None of 25 patients treated in this fashion had a seroma in excess of 2 cc 1 month post treatment, said Dr. Kaminer.

He reported that he serves as a consultant to Cabochon and has received research funding and equipment from Cynosure.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Cellulite therapy may finally be moving out of the dark ages of overhyped claims made on behalf of interventions of little or no value to an era of treatments that actually work.

And what appears to work, according to Dr. Michael S. Kaminer, are therapies that cut the fibrous septae tethering the dermis to deeper tissues.

"I think it’s likely that the vertical pull of the fibrous septae tends to pull down on the cellulite in the skin and causes the cellulite dimples," he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

The fibrous septae theory of the etiology of cellulite is relatively new. It has gained substantial credence as a result of encouraging clinical trial data showing long-term effectiveness for two devices targeting cellulite via severing fibrous septae: the Cellulaze 1,440-nm Nd:YAG laser and the Cabochon Aesthetics controlled subcision system for subdermal undermining, according to Dr. Kaminer, who is a managing partner at SkinCare Physicians, Chestnut Hill, Mass.

Cellulaze, developed by Cynosure, recently received Food and Drug Administration marketing approval for the treatment of cellulite. It is also approved across Europe for this indication. The Cabochon device for subcutaneous release of fibrous septae in patients with cellulite is still in clinical trials.

Dr. Kaminer said Americans spend an estimated $3 billion annually on ineffective treatments for cellulite. These therapies, many of which have been the beneficiaries of claims he termed "outrageous," aim to either reduce or redistribute subcutaneous fat or to thicken the skin surface through methods such as suction massage, which creates skin edema that temporarily camouflages the cellulite dimples. Among the myriad of available therapies are skin wraps, various injectables, and focused ultrasound. But the effect sizes are small and the results, if any, last for a matter of weeks.

"Until very recently, there was absolutely no reason to pay attention to cellulite except to counsel patients as to the fact that they shouldn’t waste their money, unless they feel good about wasting their money," Dr. Kaminer said.

The situation has changed dramatically with the emergence of fibrous septae as the prime therapeutic target. Cellulaze can be used for laser lipolysis; however, in addition, the handpiece for the cannula can be turned in such a way that the laser beam can be used like a saw to cut through the fibrous septae, with resultant long-term improvement in cellulite.

In U.S. clinical trials, the average increase in skin thickness following Cellulaze therapy was 23% at 1 month and 27% at 1 year. Skin elasticity improved over baseline by 32.5% at 1 month and 21% at 1 year. Sixty-eight percent of patients demonstrated significant improvement in cellulite based upon analysis of photographs, as did 65% when assessed by Vectra 3D surface imaging.

Patient self-evaluations rated the results as good to excellent at 1 month in 76% of cases. Physicians judged the results as good to excellent in 69% of cases. These results have held up at 1 year of follow-up, noted Dr. Kaminer, who also is with the dermatology departments of Yale University, New Haven, Conn.; Dartmouth College, Hanover, N.H.; and Brown University, Providence, R.I.

The downside of Cellulaze is that it is an invasive therapy that requires tumescent anesthesia. And given that the history of the field of cellulite therapy is one of hype far in excess of reality, Dr. Kaminer indicated that a healthy skepticism is appropriate.

"For me, I’m going to approach this with caution. I think Cellulaze is a great idea, and I think it gets to what many people believe is the root of cellulite. But I’d like to see it around for a little longer before we all jump on the bandwagon," he said.

The Cabochon system draws a small section of skin affected by cellulite into a handpiece so that a percutaneously inserted cutting tool can be utilized to cut the fibrous septae. Dr. Kaminer was an investigator in a two-site, 56-patient clinical trial with a 6- to 12-month follow-up.

In independent blinded physician review of before and after photos, 78% of patients were judged to have improved at least one full grade in severity at 6 months, such that, for example, those whose cellulite was rated severe at baseline were judged to have moderate or mild cellulite at follow-up.

At baseline, the average cellulite severity score was about 4.5 on a 0-6 scale. At 90 days, the average severity score had dropped to 3, and at 180 days to roughly 2.5. Ninety-four percent of patients were rated by independent physicians as having improved by at least 1 point on the 0-6 scale.

Of the 33 U.S. patients followed for 1 year, 87% felt their appearance was improved and 77% were satisfied with their treatment at all time points.

Seroma formation was an issue early on, until investigators realized the problem resulted from treating adjacent sites at the same depth. Seven of 31 patients treated in that manner had a seroma in excess of 2 cc at 1 month’s follow-up. But once operators began utilizing the device’s automated guidance system to vary the cutting depth at adjacent sites – for example, treating one area at a depth of 6 mm and an adjacent area at 10 mm of depth seromas were no longer a problem. None of 25 patients treated in this fashion had a seroma in excess of 2 cc 1 month post treatment, said Dr. Kaminer.

He reported that he serves as a consultant to Cabochon and has received research funding and equipment from Cynosure.

SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Cellulite therapy may finally be moving out of the dark ages of overhyped claims made on behalf of interventions of little or no value to an era of treatments that actually work.

And what appears to work, according to Dr. Michael S. Kaminer, are therapies that cut the fibrous septae tethering the dermis to deeper tissues.

"I think it’s likely that the vertical pull of the fibrous septae tends to pull down on the cellulite in the skin and causes the cellulite dimples," he explained at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF).

Bruce Jancin/IMNG Medical Media

The fibrous septae theory of the etiology of cellulite is relatively new. It has gained substantial credence as a result of encouraging clinical trial data showing long-term effectiveness for two devices targeting cellulite via severing fibrous septae: the Cellulaze 1,440-nm Nd:YAG laser and the Cabochon Aesthetics controlled subcision system for subdermal undermining, according to Dr. Kaminer, who is a managing partner at SkinCare Physicians, Chestnut Hill, Mass.

Cellulaze, developed by Cynosure, recently received Food and Drug Administration marketing approval for the treatment of cellulite. It is also approved across Europe for this indication. The Cabochon device for subcutaneous release of fibrous septae in patients with cellulite is still in clinical trials.

Dr. Kaminer said Americans spend an estimated $3 billion annually on ineffective treatments for cellulite. These therapies, many of which have been the beneficiaries of claims he termed "outrageous," aim to either reduce or redistribute subcutaneous fat or to thicken the skin surface through methods such as suction massage, which creates skin edema that temporarily camouflages the cellulite dimples. Among the myriad of available therapies are skin wraps, various injectables, and focused ultrasound. But the effect sizes are small and the results, if any, last for a matter of weeks.

"Until very recently, there was absolutely no reason to pay attention to cellulite except to counsel patients as to the fact that they shouldn’t waste their money, unless they feel good about wasting their money," Dr. Kaminer said.

The situation has changed dramatically with the emergence of fibrous septae as the prime therapeutic target. Cellulaze can be used for laser lipolysis; however, in addition, the handpiece for the cannula can be turned in such a way that the laser beam can be used like a saw to cut through the fibrous septae, with resultant long-term improvement in cellulite.

In U.S. clinical trials, the average increase in skin thickness following Cellulaze therapy was 23% at 1 month and 27% at 1 year. Skin elasticity improved over baseline by 32.5% at 1 month and 21% at 1 year. Sixty-eight percent of patients demonstrated significant improvement in cellulite based upon analysis of photographs, as did 65% when assessed by Vectra 3D surface imaging.

Patient self-evaluations rated the results as good to excellent at 1 month in 76% of cases. Physicians judged the results as good to excellent in 69% of cases. These results have held up at 1 year of follow-up, noted Dr. Kaminer, who also is with the dermatology departments of Yale University, New Haven, Conn.; Dartmouth College, Hanover, N.H.; and Brown University, Providence, R.I.

The downside of Cellulaze is that it is an invasive therapy that requires tumescent anesthesia. And given that the history of the field of cellulite therapy is one of hype far in excess of reality, Dr. Kaminer indicated that a healthy skepticism is appropriate.

"For me, I’m going to approach this with caution. I think Cellulaze is a great idea, and I think it gets to what many people believe is the root of cellulite. But I’d like to see it around for a little longer before we all jump on the bandwagon," he said.

The Cabochon system draws a small section of skin affected by cellulite into a handpiece so that a percutaneously inserted cutting tool can be utilized to cut the fibrous septae. Dr. Kaminer was an investigator in a two-site, 56-patient clinical trial with a 6- to 12-month follow-up.

In independent blinded physician review of before and after photos, 78% of patients were judged to have improved at least one full grade in severity at 6 months, such that, for example, those whose cellulite was rated severe at baseline were judged to have moderate or mild cellulite at follow-up.

At baseline, the average cellulite severity score was about 4.5 on a 0-6 scale. At 90 days, the average severity score had dropped to 3, and at 180 days to roughly 2.5. Ninety-four percent of patients were rated by independent physicians as having improved by at least 1 point on the 0-6 scale.

Of the 33 U.S. patients followed for 1 year, 87% felt their appearance was improved and 77% were satisfied with their treatment at all time points.

Seroma formation was an issue early on, until investigators realized the problem resulted from treating adjacent sites at the same depth. Seven of 31 patients treated in that manner had a seroma in excess of 2 cc at 1 month’s follow-up. But once operators began utilizing the device’s automated guidance system to vary the cutting depth at adjacent sites – for example, treating one area at a depth of 6 mm and an adjacent area at 10 mm of depth seromas were no longer a problem. None of 25 patients treated in this fashion had a seroma in excess of 2 cc 1 month post treatment, said Dr. Kaminer.

He reported that he serves as a consultant to Cabochon and has received research funding and equipment from Cynosure.

SDEF and this news organization are owned by Elsevier.

Dr. Susan Weinkle explains how dermatologists can use a foot pedal-operated device to facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Reporter Damian McNamara reports live from the South Beach Symposium in Miami.

Dr. Susan Weinkle explains how dermatologists can use a foot pedal-operated device to facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Reporter Damian McNamara reports live from the South Beach Symposium in Miami.

Dr. Susan Weinkle explains how dermatologists can use a foot pedal-operated device to facilitate high viscosity filler injections and minimize hand fatigue from multiple injections.

Reporter Damian McNamara reports live from the South Beach Symposium in Miami.

Dyspigmentation from acne or inflammatory skin disease is a frustrating problem for both patients and dermatologists.

Postinflammatory hyperpigmentation can last up to 2 years without proper treatment. Dark skin individuals (skin types IV-VI) often have dyschromia, while lighter skin patients (skin types I-III) can have both dyschromia and erythema.

For dyschromia and erythema, cosmeceutical skin care preparations with green tea polyphenols, caffeine, niacinamide, grape seed extract, or coffeeberry may help reduce the inflammation associated with acne scars.

For darker skinned patients, hydroquinone is still the mainstay of therapy. Many dermatologists, given the risks, have shied away from hydroquinone 4% creams. Most of these risks, however, are associated with long-term use.

Short-term, higher dose treatment regimens are more efficacious, have less reported risks, encourage repeated use, and ensure greater compliance as patients see quick results.

Short bursts of compounded hydroquinone has excellent results in skin of color patients. In my practice, I use hydroquinone 8%-10% mixed with retinoic acid 0.025% cream and hydrocortisone 1% cream applied at bedtime for a maximum of 6-8 weeks on acne scars or melasma. This short pulse therapy provides immediate lightening of dark spots and minimizes the risks associated with long-term hydroquinone use.

Patients must be counseled about the risks of ochronosis: They cannot be pregnant, nursing or planning to become pregnant. The skin of some patients may become irritated; for these patients I switch to every-other-day dosing.

After 6-8 weeks of compounded hydroquinone treatment, a step-down treatment regimen – including glycolic acid peels or topical agents like broad spectrum sunscreens and preparations containing arbutin, niacinamide, soy, licorice root extract, or bearberry – provide excellent treatments for continued skin lightening.

- Lily Talakoub, M.D.

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

Dyspigmentation from acne or inflammatory skin disease is a frustrating problem for both patients and dermatologists.

Postinflammatory hyperpigmentation can last up to 2 years without proper treatment. Dark skin individuals (skin types IV-VI) often have dyschromia, while lighter skin patients (skin types I-III) can have both dyschromia and erythema.

For dyschromia and erythema, cosmeceutical skin care preparations with green tea polyphenols, caffeine, niacinamide, grape seed extract, or coffeeberry may help reduce the inflammation associated with acne scars.

For darker skinned patients, hydroquinone is still the mainstay of therapy. Many dermatologists, given the risks, have shied away from hydroquinone 4% creams. Most of these risks, however, are associated with long-term use.

Short-term, higher dose treatment regimens are more efficacious, have less reported risks, encourage repeated use, and ensure greater compliance as patients see quick results.

Short bursts of compounded hydroquinone has excellent results in skin of color patients. In my practice, I use hydroquinone 8%-10% mixed with retinoic acid 0.025% cream and hydrocortisone 1% cream applied at bedtime for a maximum of 6-8 weeks on acne scars or melasma. This short pulse therapy provides immediate lightening of dark spots and minimizes the risks associated with long-term hydroquinone use.

Patients must be counseled about the risks of ochronosis: They cannot be pregnant, nursing or planning to become pregnant. The skin of some patients may become irritated; for these patients I switch to every-other-day dosing.

After 6-8 weeks of compounded hydroquinone treatment, a step-down treatment regimen – including glycolic acid peels or topical agents like broad spectrum sunscreens and preparations containing arbutin, niacinamide, soy, licorice root extract, or bearberry – provide excellent treatments for continued skin lightening.

- Lily Talakoub, M.D.

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

Dyspigmentation from acne or inflammatory skin disease is a frustrating problem for both patients and dermatologists.

Postinflammatory hyperpigmentation can last up to 2 years without proper treatment. Dark skin individuals (skin types IV-VI) often have dyschromia, while lighter skin patients (skin types I-III) can have both dyschromia and erythema.

For dyschromia and erythema, cosmeceutical skin care preparations with green tea polyphenols, caffeine, niacinamide, grape seed extract, or coffeeberry may help reduce the inflammation associated with acne scars.

For darker skinned patients, hydroquinone is still the mainstay of therapy. Many dermatologists, given the risks, have shied away from hydroquinone 4% creams. Most of these risks, however, are associated with long-term use.

Short-term, higher dose treatment regimens are more efficacious, have less reported risks, encourage repeated use, and ensure greater compliance as patients see quick results.

Short bursts of compounded hydroquinone has excellent results in skin of color patients. In my practice, I use hydroquinone 8%-10% mixed with retinoic acid 0.025% cream and hydrocortisone 1% cream applied at bedtime for a maximum of 6-8 weeks on acne scars or melasma. This short pulse therapy provides immediate lightening of dark spots and minimizes the risks associated with long-term hydroquinone use.

Patients must be counseled about the risks of ochronosis: They cannot be pregnant, nursing or planning to become pregnant. The skin of some patients may become irritated; for these patients I switch to every-other-day dosing.

After 6-8 weeks of compounded hydroquinone treatment, a step-down treatment regimen – including glycolic acid peels or topical agents like broad spectrum sunscreens and preparations containing arbutin, niacinamide, soy, licorice root extract, or bearberry – provide excellent treatments for continued skin lightening.

- Lily Talakoub, M.D.

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

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

MIAMI BEACH – It may now be possible for patients to experience the benefits of hyaluronic acid fillers without a needle, according to investigators.

In a double-blind, controlled study of 100 women with moderate to severe photo-damaged skin, a novel nanotechnology was used to shepherd topical hyaluronic acid through the dermis, essentially overcoming the large particle size hurdle of years past.

Significant improvements in overall efficacy, skin roughness, and "smoothing effect" were observed after 90 days. Blinded observers reported the benefits in 40 women who applied topical cross-linked hyaluronic acid (Restylane) twice a day to their full face, compared with 20 women who applied the nanotechnology vehicle only. Additional significant improvements were seen among another 40 women who applied non-cross linked topical hyaluronic acid using the same regimen.

"We know the skin is a barrier. It acts as a barrier for things getting in, but it can also prevent topical compounds from getting in," said Dr. Glynis R. Ablon, who is on the dermatology faculty at the University of California, Los Angeles.

"Topical hyaluronic acid does appear to be penetrating the skin with this unique Ionic Nano Particle Technology [INParT] delivery system," she said.

The potential for Transdermal Corp’s INParT extends beyond patients with photo-damaged skin and could provide additional therapeutic options for acne, rosacea, psoriasis, and melasma, said Dr. Ablon, at the South Beach Symposium.

Dr. Ablon and her colleague Dr. Mark S. Nestor conducted the study at two U.S. sites. Participants were 35 to 65 years old and evaluated at days 15, 45, 90, and 120 (following a 4-week washout period).

They assessed six parameters. For example, at 120 days, the percentage of patients with skin roughness rated as "smooth" or "very smooth" was 100% of the cross linked group, 88% of the non-cross linked group, and 55% of controls. Similarly, at 20 weeks skin ratings of "hydrated" or "very hydrated" were reported for 100% of the cross-linked group, 87% of the non-cross linked group, and 52% of controls.

Similar improvements in skin elasticity, skin radiance, and "smoothing effect" were also observed.

The raters also measured overall efficacy at the same time point. The percentage of patients who reported good or excellent overall efficacy was 93% in the cross-linked group, 35% in the non-cross linked group, and 0% in the control group.

Topical hyaluronic acid "appears to have a significant aesthetic enhancement effect," Dr. Ablon said.

Interestingly, skin roughness, hydration, and elasticity ratings continued to improve even after 90 days in the cross-linked hyaluronic acid group, Dr. Ablon said. This finding suggests collagen remodeling took place.

The researchers also assessed how well participants accepted the therapy at 12 weeks. "Tolerance was 100% across the board," Dr. Ablon said.

Transdermal Corp funded this study through an unrestricted educational grant. Dr. Ablon and Dr. Nestor are consultants and investigators for Transdermal Corp. Dr. Ablon also is an investigator and advisory board member for Medicis, which markets Restylane. Dr. Nestor is an investigator, consultant, speaker, and advisory board member for Medicis.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.

WAIKOLOA, HAWAII – Dr. Brett M. Coldiron is a sort of latter-day Paul Revere, travelling far and wide to spread the alarm to his fellow dermatologists – not of Redcoats a’coming, but of the need to prepare for looming economic hard times.

"I wasn’t invited to speak at your meeting, so I invited myself," he declared by way of introduction at the Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation (SDEF), as he launched into an analysis of dermatology’s near-term financial future.

"I’m here to present your 5-year economic plan – what you can expect. I think you can plan your next 5 years based on these predictions. It’s not pretty; and it’s not kind," cautioned Dr. Coldiron, whose expertise regarding health care policy and reform has been forged through long-term involvement representing dermatology on the American Medical Association’s Relative Value Scale Update, Health Care Finance, and Government Health Care Policy committees.

His core message to his colleagues boiled down to this: "Don’t build palaces. It’s time to hunker down."

Dermatology is a heavily procedurally oriented, small specialty – less then 1% of all physicians – which has experienced dramatic growth in procedure volume over the past couple decades. As such, it is a high-priority target for congressional cost-cutting efforts. In the first 4 months of next year, Dr. Coldiron said he expects reimbursement for codes pertaining to actinic keratosis treatment to be cut by 25%-50%, along with a roughly 20% reduction in payment for Mohs surgery. And that’s just the beginning.

Dermatology and other small specialties will bear the brunt of any cost-savings attempts by Congress. Dermatology has powerful enemies in Congress, the Centers for Medicare and Medicaid Services, and the American Medical Association, who view dermatologists as overpaid, wasteful abusers of the system, explained Dr. Coldiron, who is president of the American College of Mohs Surgery and a 2013 member of the American Academy of Dermatology’s board of directors.

Among his predictions for the next 5 years:

• Hospitals and pharmacies, if squeezed too hard, will simply close. Insurers will move into other lines of business coverage. Pharmaceutical companies will reduce their research and development budgets. Thus, reducing physician income will be one of the few politically acceptable health care cost-cutting avenues available.

• There will be more bundling of minor procedures into evaluation and management fees.

• The government will attempt to force all physicians to accept Medicaid. "They’ll probably try to tie it to your acceptance of Medicare. Or maybe they’ll say, ‘We paid for 4 years of postgraduate education; now you owe us 4 years of taking Medicaid,’ " he said.

• The use of physician assistants and nurse practitioners will grow in dermatology. This will result in increased utilization and more intense billing audits along with reimbursement cuts aimed at cancelling out the economic impact of greater utilization.

• Cosmetic procedures and reconstructive surgery will remain safe havens. "They may try to pass a cosmetic procedure tax, but I think the fact that you have another source of income is very important," noted Dr. Coldiron, a dermatologist at the University of Cincinnati.

He recommended that dermatologists temper their income projections for the coming half-decade: "Don’t promise big salaries to new associates, only a percentage of income collected."

Also, read the fine print before jumping on board one of the accountable care organizations that are springing up. "This is government-driven managed care with capitation. What they’re going to do is extract from the specialists and give back to primary care. It’s kind of a loser’s game," he said.

Beyond the next 5 years, however, the outlook for dermatology is bright, Dr. Coldiron stressed.

"Be strong. We are not greedy specialists; we are a frontline specialty fighting an epidemic of skin cancer. We are needed by our patients and by the health care system. The pendulum will eventually swing back our way," he concluded.

Dr. Coldiron reported having no relevant financial conflicts. SDEF and this news organization are owned by Elsevier.

Why is it that office visits for pigmentary disorders, such as vitiligo and hypo- and hyperpigmentation, are often covered by many health insurance plans but a diagnosis code for melasma is not?

Additionally, why are the treatments for vitiligo – including prescriptions such as corticosteroids and phototherapy – covered but treatments for melasma – including topical hydroquinone, chemical peels, and lasers – are not?

I've searched for answers to the these questions, even discussing them with my billing office, but the only answer I've been able to get is that insurance companies consider melasma to be "cosmetic." Even though both conditions may alter a person's appearance and cause cosmetic concerns, vitiligo has been delineated a medical condition because of research demonstrating that the etiology of vitiligo is autoimmune.

While melasma, like photoaging, does harbor sun exposure as a significant factor in the etiology and severity of the condition, melasma is not always due to sun exposure alone.

It has been well-documented that there is often a genetic predisposition and hormonal contribution to melasma. In clinical practice, we often see patients with hormonal shifts, because of either pregnancy or hormonal contraceptives, that develop melasma despite vigorous photoprotection.

Maybe if, in the future, a specific inherited gene is identified that shows a predisposition to melasma in certain individuals, the coverage may change.

Last year, a study was published in the Journal of Investigative Dermatology that identified upregulation of expression of certain genes associated with tyrosinase and Wnt in skin affected by melasma, as well as a down regulation of lipid metabolism associated genes, when compared with non-lesional skin (J. Invest. Dermatol. 2011;131:1692-700).

This type of research is a step in the right direction in identifying the true etiology of melasma. Until we find an answer, does anyone have any other insight as to why insurance coverage is the way it is?

- Naissan Wesley, M.D.

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

Why is it that office visits for pigmentary disorders, such as vitiligo and hypo- and hyperpigmentation, are often covered by many health insurance plans but a diagnosis code for melasma is not?

Additionally, why are the treatments for vitiligo – including prescriptions such as corticosteroids and phototherapy – covered but treatments for melasma – including topical hydroquinone, chemical peels, and lasers – are not?

I've searched for answers to the these questions, even discussing them with my billing office, but the only answer I've been able to get is that insurance companies consider melasma to be "cosmetic." Even though both conditions may alter a person's appearance and cause cosmetic concerns, vitiligo has been delineated a medical condition because of research demonstrating that the etiology of vitiligo is autoimmune.

While melasma, like photoaging, does harbor sun exposure as a significant factor in the etiology and severity of the condition, melasma is not always due to sun exposure alone.

It has been well-documented that there is often a genetic predisposition and hormonal contribution to melasma. In clinical practice, we often see patients with hormonal shifts, because of either pregnancy or hormonal contraceptives, that develop melasma despite vigorous photoprotection.

Maybe if, in the future, a specific inherited gene is identified that shows a predisposition to melasma in certain individuals, the coverage may change.

Last year, a study was published in the Journal of Investigative Dermatology that identified upregulation of expression of certain genes associated with tyrosinase and Wnt in skin affected by melasma, as well as a down regulation of lipid metabolism associated genes, when compared with non-lesional skin (J. Invest. Dermatol. 2011;131:1692-700).

This type of research is a step in the right direction in identifying the true etiology of melasma. Until we find an answer, does anyone have any other insight as to why insurance coverage is the way it is?

- Naissan Wesley, M.D.

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

Why is it that office visits for pigmentary disorders, such as vitiligo and hypo- and hyperpigmentation, are often covered by many health insurance plans but a diagnosis code for melasma is not?

Additionally, why are the treatments for vitiligo – including prescriptions such as corticosteroids and phototherapy – covered but treatments for melasma – including topical hydroquinone, chemical peels, and lasers – are not?

I've searched for answers to the these questions, even discussing them with my billing office, but the only answer I've been able to get is that insurance companies consider melasma to be "cosmetic." Even though both conditions may alter a person's appearance and cause cosmetic concerns, vitiligo has been delineated a medical condition because of research demonstrating that the etiology of vitiligo is autoimmune.

While melasma, like photoaging, does harbor sun exposure as a significant factor in the etiology and severity of the condition, melasma is not always due to sun exposure alone.

It has been well-documented that there is often a genetic predisposition and hormonal contribution to melasma. In clinical practice, we often see patients with hormonal shifts, because of either pregnancy or hormonal contraceptives, that develop melasma despite vigorous photoprotection.

Maybe if, in the future, a specific inherited gene is identified that shows a predisposition to melasma in certain individuals, the coverage may change.

Last year, a study was published in the Journal of Investigative Dermatology that identified upregulation of expression of certain genes associated with tyrosinase and Wnt in skin affected by melasma, as well as a down regulation of lipid metabolism associated genes, when compared with non-lesional skin (J. Invest. Dermatol. 2011;131:1692-700).

This type of research is a step in the right direction in identifying the true etiology of melasma. Until we find an answer, does anyone have any other insight as to why insurance coverage is the way it is?

- Naissan Wesley, M.D.

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

In the East, the nut from the inedible fruit of the Ginkgo biloba tree, believed to be the oldest living tree species, has been a popular medical elixir, as well as food item, for many years. People in the West may be most familiar with Ginkgo biloba for the fetid odor of its fruit. During the last 15 years, though, the plant has become well known here for its use as a dietary supplement to treat dementia and memory loss (Arch. Neurol. 1998;55:1409-15; Public Health Nutr. 2000;3:495-9). Ginkgo is also believed to possess properties capable of imparting healthy benefits to human skin.

Photo: Zlatko Ivancok/Fotolia.com

Medical Uses

In China and Japan, the leaves and nuts of the ginkgo tree have been used for thousands of years to treat various medical conditions, including poor circulation; hypertension; poor memory, dementia, and depression, particularly among the aged; male impotence; and disorders related to an inner-ear imbalance, such as deafness, tinnitus, and vertigo (Hori T, et al. Ginkgo Biloba: A Global Treasure. Berlin, Springer-Verlag, 1997).

Currently, ginkgo is used globally to treat depression, usually in the elderly, and circulatory problems (for example, cerebrovascular and peripheral vascular insufficiency).

G. biloba contains quercetin, which is one of the most abundant natural flavonoids (Clin. Exp. Dermatol. 2001;26:536-9; Free Radic. Biol. Med. 1998;25:196-200). Discussed in a recent column, quercetin is gaining a reputation as a potent antioxidant, conferring significant anti-inflammatory activity. Ginkgo also contains various other flavonoids with demonstrated antioxidant and anti-inflammatory activities against cyclooxygenase (COX) and lipoxygenase (J. Pharm. Pharmacol. 1988;40:787-92; Biochem. Pharmacol. 1993;45:13-9).

It is not surprising, then, that ginkgo is developing a similar reputation as a significant antioxidant and anti-inflammatory agent (Br. J. Dermatol. 2003;149:681-91).

The G. biloba extract EGb 761, prepared from the tree’s leaves, is a natural mixture containing flavone glycosides (33%), mostly quercetin and kaempferol derivatives, and terpenes (6%), that has been used or evaluated for the treatment of stroke, aging, and some adverse drug effects (Biomed. Papers 2003;147:137-45).

This extract has also exhibited the capacity to halt lipoperoxidation by scavenging peroxyl radicals (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20; Pharm. Pharmacol. 1999;51:1435-40; Biochem. Pharmacol. 1995;49:1649-55) and reduce the number of UVB-induced sunburn cells in mice (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20).

In a study of the effects of ginkgetin, a biflavone component of G. biloba leaves reported to confer significant antiarthritic and analgesic activity in rats, ginkgetin down-regulated COX-2 in the dorsal skin of ICR mice treated with 12-O-tetradecanoylphorbol 13-acetate (TPA) and the topical application of both ginkgetin and a mostly 1:1 biflavonoid mixture of ginkgetin and isoginkgetin, from G. biloba leaves, dose-dependently inhibited skin inflammation of croton oil–induced ear edema in mice. Researchers concluded that the capacity of this biflavone constituent of ginkgo leaves to down-regulate COX-2 indicates anti-inflammatory activity against cutaneous inflammation (Planta Med. 2002;68:316-21).

Established in earlier research, the discrete effects of G. biloba extracts such as quercetin and sciadopitysin on UVB-irradiated cultured normal human skin fibroblasts were investigated by researchers using a neutral red dye uptake assay and a lactic dehydrogenase (LDH) release assay. The reduced cytotoxicity observed suggested that the structure-related activity might account for the antioxidant potential of biflavones of G. biloba as well as hydroxy- and methyl-substitutions on the basic structure of these flavonoids (J. Dermatol. 2001;28:193-9).

Anti-Inflammatory and Antioxidant Properties

With the fairly expansive range of applications associated with antioxidant and anti-inflammatory agents, it seems reasonable to expect that ginkgo will join the legion of popular botanical products studied as potential therapies for numerous conditions. In a double-blind placebo-controlled trial in which 47 patients were evaluated, investigators assessed the efficacy of G. biloba extract in controlling limited and slow-spreading vitiligo and promoting repigmentation in affected areas. One group of patients was administered 40 mg G. biloba extract three times daily the other group received the same doses of placebo. Researchers observed a statistically significant cessation of depigmentation in patients treated with G. biloba, with notable to complete repigmentation seen in 10 patients from the treated group, but only two patients in the placebo group. This study lends support to the notion that G. biloba extract may be an effective, safe approach to arresting the progression of vitiligo (Clin. Exp. Dermatol. 2003;28:285-7).

In a study evaluating the effect of orally administered G. biloba extract on UVB-irradiated mouse skin, investigators measured superoxide dismutase (SOD) activity and zinc levels. Zinc, an essential element that acts as a cofactor in some metabolic processes, has reported antioxidant activity and is typically found in high concentrations in the skin. Both SOD activity and zinc levels decreased after UVB exposure in comparison to the control group; after ginkgo treatment, measurement increased, compared with untreated UVB-exposed group (Biol. Trace Elem. Res. 2001;80:175-9). In a previous study, ginkgo extracts exhibited SOD-like activity (Experientia 1989;45:708-12).

Researchers conducted in vitro and in vivo studies of the activity of terpene-free G. biloba extract containing 33% ginkgo flavone glycosides, mostly quercetin and kaempferol derivatives, with the antioxidant SOD as a positive control. Results of both the in vitro electron spin resonance (ESR) assays and in vivo experiments on anti-inflammatory models with cutaneous blood flux measured by a laser Doppler perfusion imager, corroborated the antioxidant and anti-inflammatory properties of the ginkgo extract and its capacity for protecting skin from free radical damage. This study also indicated an optimal concentration for ginkgo extract, above or below which its beneficial actions subside (J. Pharm. Pharmacol. 1999;51:1435-40).

In an earlier study, ginkgo extracts, particularly the flavonoid components quercetin, kaempferol, sciadopitysin, ginkgetin, and isoginkgetin, were shown to enhance the proliferation of normal human skin fibroblast in vitro as measured by MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide) assay and direct hemocytometer cell count. Various additional assays of fibroblasts incubated with G. biloba extracts and ascorbic acid and controls incubated only with ascorbic acid demonstrated increased collagen and extracellular fibronectin synthesis in the treatment group (Skin Pharmacol. 1997;10:200-5).

Products

Like many herbal ingredients, ginkgo is used in a small but growing number of topical products. The Hydramax Ginkgo Biloba PhytoSerum (1 fl. oz./$15.50) is a moisturizer intended to restore chapped and severely dehydrated skin. The product is formulated with 2% standardized time-released phytoliposomes of G. biloba and buttressed by a cocktail of organic herb concentrates of white willow bark, ivy, comfrey, chamomile, mallow, and G. biloba as well as numerous emollient and essential oils in an organic aloe vera serum.

The Rejuvenex Body Lotion (6 oz./$21.60) features a highly purified alpha-glycolic acid, but includes ginkgo extract and vitamin E to protect against the skin irritation that high concentrations of glycolic acid can engender.

Ginkgo extract is increasingly found among the lists of the unadvertised or inactive ingredients in more and more topical skin care products. For example, two of the three products in the emerginC Crease Ease Kit ($250) – the emerginC crease ease emulsion (50 ml) and the emerginC crease ease gel (eye/lip area – 30 mL) – contain G. biloba along with a long list of other herbal ingredients.

Conclusion

Whether in oral or topical form, G. biloba extracts do not reek like the fruit of the tree; otherwise, such products might never make their way to the shelf. Use in aromatherapy would also be precluded. Fortunately, the offensive odor dissipates after separation of the nut from the seed shell and subsequent cleaning.

In topical products, various components of ginkgo are used more often as ancillary ingredients, though some formulations now feature this increasingly popular herbal ingredient. Preliminary research suggests reasons for optimism and should spur further investigation as to the overall health benefits conferred by G. biloba.

The research on vitiligo is particularly compelling from a dermatologic perspective. More study is required to ascertain whether topical formulations can harness the apparent antioxidant and anti-inflammatory effects to confer significant cutaneous benefits. More randomized controlled trials will build on what is currently a small but intriguing body of evidence.

In the East, the nut from the inedible fruit of the Ginkgo biloba tree, believed to be the oldest living tree species, has been a popular medical elixir, as well as food item, for many years. People in the West may be most familiar with Ginkgo biloba for the fetid odor of its fruit. During the last 15 years, though, the plant has become well known here for its use as a dietary supplement to treat dementia and memory loss (Arch. Neurol. 1998;55:1409-15; Public Health Nutr. 2000;3:495-9). Ginkgo is also believed to possess properties capable of imparting healthy benefits to human skin.

Photo: Zlatko Ivancok/Fotolia.com

Medical Uses

In China and Japan, the leaves and nuts of the ginkgo tree have been used for thousands of years to treat various medical conditions, including poor circulation; hypertension; poor memory, dementia, and depression, particularly among the aged; male impotence; and disorders related to an inner-ear imbalance, such as deafness, tinnitus, and vertigo (Hori T, et al. Ginkgo Biloba: A Global Treasure. Berlin, Springer-Verlag, 1997).

Currently, ginkgo is used globally to treat depression, usually in the elderly, and circulatory problems (for example, cerebrovascular and peripheral vascular insufficiency).

G. biloba contains quercetin, which is one of the most abundant natural flavonoids (Clin. Exp. Dermatol. 2001;26:536-9; Free Radic. Biol. Med. 1998;25:196-200). Discussed in a recent column, quercetin is gaining a reputation as a potent antioxidant, conferring significant anti-inflammatory activity. Ginkgo also contains various other flavonoids with demonstrated antioxidant and anti-inflammatory activities against cyclooxygenase (COX) and lipoxygenase (J. Pharm. Pharmacol. 1988;40:787-92; Biochem. Pharmacol. 1993;45:13-9).

It is not surprising, then, that ginkgo is developing a similar reputation as a significant antioxidant and anti-inflammatory agent (Br. J. Dermatol. 2003;149:681-91).

The G. biloba extract EGb 761, prepared from the tree’s leaves, is a natural mixture containing flavone glycosides (33%), mostly quercetin and kaempferol derivatives, and terpenes (6%), that has been used or evaluated for the treatment of stroke, aging, and some adverse drug effects (Biomed. Papers 2003;147:137-45).

This extract has also exhibited the capacity to halt lipoperoxidation by scavenging peroxyl radicals (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20; Pharm. Pharmacol. 1999;51:1435-40; Biochem. Pharmacol. 1995;49:1649-55) and reduce the number of UVB-induced sunburn cells in mice (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20).

In a study of the effects of ginkgetin, a biflavone component of G. biloba leaves reported to confer significant antiarthritic and analgesic activity in rats, ginkgetin down-regulated COX-2 in the dorsal skin of ICR mice treated with 12-O-tetradecanoylphorbol 13-acetate (TPA) and the topical application of both ginkgetin and a mostly 1:1 biflavonoid mixture of ginkgetin and isoginkgetin, from G. biloba leaves, dose-dependently inhibited skin inflammation of croton oil–induced ear edema in mice. Researchers concluded that the capacity of this biflavone constituent of ginkgo leaves to down-regulate COX-2 indicates anti-inflammatory activity against cutaneous inflammation (Planta Med. 2002;68:316-21).

Established in earlier research, the discrete effects of G. biloba extracts such as quercetin and sciadopitysin on UVB-irradiated cultured normal human skin fibroblasts were investigated by researchers using a neutral red dye uptake assay and a lactic dehydrogenase (LDH) release assay. The reduced cytotoxicity observed suggested that the structure-related activity might account for the antioxidant potential of biflavones of G. biloba as well as hydroxy- and methyl-substitutions on the basic structure of these flavonoids (J. Dermatol. 2001;28:193-9).

Anti-Inflammatory and Antioxidant Properties

With the fairly expansive range of applications associated with antioxidant and anti-inflammatory agents, it seems reasonable to expect that ginkgo will join the legion of popular botanical products studied as potential therapies for numerous conditions. In a double-blind placebo-controlled trial in which 47 patients were evaluated, investigators assessed the efficacy of G. biloba extract in controlling limited and slow-spreading vitiligo and promoting repigmentation in affected areas. One group of patients was administered 40 mg G. biloba extract three times daily the other group received the same doses of placebo. Researchers observed a statistically significant cessation of depigmentation in patients treated with G. biloba, with notable to complete repigmentation seen in 10 patients from the treated group, but only two patients in the placebo group. This study lends support to the notion that G. biloba extract may be an effective, safe approach to arresting the progression of vitiligo (Clin. Exp. Dermatol. 2003;28:285-7).

In a study evaluating the effect of orally administered G. biloba extract on UVB-irradiated mouse skin, investigators measured superoxide dismutase (SOD) activity and zinc levels. Zinc, an essential element that acts as a cofactor in some metabolic processes, has reported antioxidant activity and is typically found in high concentrations in the skin. Both SOD activity and zinc levels decreased after UVB exposure in comparison to the control group; after ginkgo treatment, measurement increased, compared with untreated UVB-exposed group (Biol. Trace Elem. Res. 2001;80:175-9). In a previous study, ginkgo extracts exhibited SOD-like activity (Experientia 1989;45:708-12).

Researchers conducted in vitro and in vivo studies of the activity of terpene-free G. biloba extract containing 33% ginkgo flavone glycosides, mostly quercetin and kaempferol derivatives, with the antioxidant SOD as a positive control. Results of both the in vitro electron spin resonance (ESR) assays and in vivo experiments on anti-inflammatory models with cutaneous blood flux measured by a laser Doppler perfusion imager, corroborated the antioxidant and anti-inflammatory properties of the ginkgo extract and its capacity for protecting skin from free radical damage. This study also indicated an optimal concentration for ginkgo extract, above or below which its beneficial actions subside (J. Pharm. Pharmacol. 1999;51:1435-40).

In an earlier study, ginkgo extracts, particularly the flavonoid components quercetin, kaempferol, sciadopitysin, ginkgetin, and isoginkgetin, were shown to enhance the proliferation of normal human skin fibroblast in vitro as measured by MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide) assay and direct hemocytometer cell count. Various additional assays of fibroblasts incubated with G. biloba extracts and ascorbic acid and controls incubated only with ascorbic acid demonstrated increased collagen and extracellular fibronectin synthesis in the treatment group (Skin Pharmacol. 1997;10:200-5).

Products

Like many herbal ingredients, ginkgo is used in a small but growing number of topical products. The Hydramax Ginkgo Biloba PhytoSerum (1 fl. oz./$15.50) is a moisturizer intended to restore chapped and severely dehydrated skin. The product is formulated with 2% standardized time-released phytoliposomes of G. biloba and buttressed by a cocktail of organic herb concentrates of white willow bark, ivy, comfrey, chamomile, mallow, and G. biloba as well as numerous emollient and essential oils in an organic aloe vera serum.

The Rejuvenex Body Lotion (6 oz./$21.60) features a highly purified alpha-glycolic acid, but includes ginkgo extract and vitamin E to protect against the skin irritation that high concentrations of glycolic acid can engender.

Ginkgo extract is increasingly found among the lists of the unadvertised or inactive ingredients in more and more topical skin care products. For example, two of the three products in the emerginC Crease Ease Kit ($250) – the emerginC crease ease emulsion (50 ml) and the emerginC crease ease gel (eye/lip area – 30 mL) – contain G. biloba along with a long list of other herbal ingredients.

Conclusion

Whether in oral or topical form, G. biloba extracts do not reek like the fruit of the tree; otherwise, such products might never make their way to the shelf. Use in aromatherapy would also be precluded. Fortunately, the offensive odor dissipates after separation of the nut from the seed shell and subsequent cleaning.

In topical products, various components of ginkgo are used more often as ancillary ingredients, though some formulations now feature this increasingly popular herbal ingredient. Preliminary research suggests reasons for optimism and should spur further investigation as to the overall health benefits conferred by G. biloba.

The research on vitiligo is particularly compelling from a dermatologic perspective. More study is required to ascertain whether topical formulations can harness the apparent antioxidant and anti-inflammatory effects to confer significant cutaneous benefits. More randomized controlled trials will build on what is currently a small but intriguing body of evidence.

In the East, the nut from the inedible fruit of the Ginkgo biloba tree, believed to be the oldest living tree species, has been a popular medical elixir, as well as food item, for many years. People in the West may be most familiar with Ginkgo biloba for the fetid odor of its fruit. During the last 15 years, though, the plant has become well known here for its use as a dietary supplement to treat dementia and memory loss (Arch. Neurol. 1998;55:1409-15; Public Health Nutr. 2000;3:495-9). Ginkgo is also believed to possess properties capable of imparting healthy benefits to human skin.

Photo: Zlatko Ivancok/Fotolia.com

Medical Uses

In China and Japan, the leaves and nuts of the ginkgo tree have been used for thousands of years to treat various medical conditions, including poor circulation; hypertension; poor memory, dementia, and depression, particularly among the aged; male impotence; and disorders related to an inner-ear imbalance, such as deafness, tinnitus, and vertigo (Hori T, et al. Ginkgo Biloba: A Global Treasure. Berlin, Springer-Verlag, 1997).

Currently, ginkgo is used globally to treat depression, usually in the elderly, and circulatory problems (for example, cerebrovascular and peripheral vascular insufficiency).

G. biloba contains quercetin, which is one of the most abundant natural flavonoids (Clin. Exp. Dermatol. 2001;26:536-9; Free Radic. Biol. Med. 1998;25:196-200). Discussed in a recent column, quercetin is gaining a reputation as a potent antioxidant, conferring significant anti-inflammatory activity. Ginkgo also contains various other flavonoids with demonstrated antioxidant and anti-inflammatory activities against cyclooxygenase (COX) and lipoxygenase (J. Pharm. Pharmacol. 1988;40:787-92; Biochem. Pharmacol. 1993;45:13-9).

It is not surprising, then, that ginkgo is developing a similar reputation as a significant antioxidant and anti-inflammatory agent (Br. J. Dermatol. 2003;149:681-91).

The G. biloba extract EGb 761, prepared from the tree’s leaves, is a natural mixture containing flavone glycosides (33%), mostly quercetin and kaempferol derivatives, and terpenes (6%), that has been used or evaluated for the treatment of stroke, aging, and some adverse drug effects (Biomed. Papers 2003;147:137-45).

This extract has also exhibited the capacity to halt lipoperoxidation by scavenging peroxyl radicals (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20; Pharm. Pharmacol. 1999;51:1435-40; Biochem. Pharmacol. 1995;49:1649-55) and reduce the number of UVB-induced sunburn cells in mice (Photodermatol. Photoimmunol. Photomed. 2002;18:117-20).

In a study of the effects of ginkgetin, a biflavone component of G. biloba leaves reported to confer significant antiarthritic and analgesic activity in rats, ginkgetin down-regulated COX-2 in the dorsal skin of ICR mice treated with 12-O-tetradecanoylphorbol 13-acetate (TPA) and the topical application of both ginkgetin and a mostly 1:1 biflavonoid mixture of ginkgetin and isoginkgetin, from G. biloba leaves, dose-dependently inhibited skin inflammation of croton oil–induced ear edema in mice. Researchers concluded that the capacity of this biflavone constituent of ginkgo leaves to down-regulate COX-2 indicates anti-inflammatory activity against cutaneous inflammation (Planta Med. 2002;68:316-21).

Established in earlier research, the discrete effects of G. biloba extracts such as quercetin and sciadopitysin on UVB-irradiated cultured normal human skin fibroblasts were investigated by researchers using a neutral red dye uptake assay and a lactic dehydrogenase (LDH) release assay. The reduced cytotoxicity observed suggested that the structure-related activity might account for the antioxidant potential of biflavones of G. biloba as well as hydroxy- and methyl-substitutions on the basic structure of these flavonoids (J. Dermatol. 2001;28:193-9).

Anti-Inflammatory and Antioxidant Properties

With the fairly expansive range of applications associated with antioxidant and anti-inflammatory agents, it seems reasonable to expect that ginkgo will join the legion of popular botanical products studied as potential therapies for numerous conditions. In a double-blind placebo-controlled trial in which 47 patients were evaluated, investigators assessed the efficacy of G. biloba extract in controlling limited and slow-spreading vitiligo and promoting repigmentation in affected areas. One group of patients was administered 40 mg G. biloba extract three times daily the other group received the same doses of placebo. Researchers observed a statistically significant cessation of depigmentation in patients treated with G. biloba, with notable to complete repigmentation seen in 10 patients from the treated group, but only two patients in the placebo group. This study lends support to the notion that G. biloba extract may be an effective, safe approach to arresting the progression of vitiligo (Clin. Exp. Dermatol. 2003;28:285-7).

In a study evaluating the effect of orally administered G. biloba extract on UVB-irradiated mouse skin, investigators measured superoxide dismutase (SOD) activity and zinc levels. Zinc, an essential element that acts as a cofactor in some metabolic processes, has reported antioxidant activity and is typically found in high concentrations in the skin. Both SOD activity and zinc levels decreased after UVB exposure in comparison to the control group; after ginkgo treatment, measurement increased, compared with untreated UVB-exposed group (Biol. Trace Elem. Res. 2001;80:175-9). In a previous study, ginkgo extracts exhibited SOD-like activity (Experientia 1989;45:708-12).

Researchers conducted in vitro and in vivo studies of the activity of terpene-free G. biloba extract containing 33% ginkgo flavone glycosides, mostly quercetin and kaempferol derivatives, with the antioxidant SOD as a positive control. Results of both the in vitro electron spin resonance (ESR) assays and in vivo experiments on anti-inflammatory models with cutaneous blood flux measured by a laser Doppler perfusion imager, corroborated the antioxidant and anti-inflammatory properties of the ginkgo extract and its capacity for protecting skin from free radical damage. This study also indicated an optimal concentration for ginkgo extract, above or below which its beneficial actions subside (J. Pharm. Pharmacol. 1999;51:1435-40).

In an earlier study, ginkgo extracts, particularly the flavonoid components quercetin, kaempferol, sciadopitysin, ginkgetin, and isoginkgetin, were shown to enhance the proliferation of normal human skin fibroblast in vitro as measured by MTT (3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide) assay and direct hemocytometer cell count. Various additional assays of fibroblasts incubated with G. biloba extracts and ascorbic acid and controls incubated only with ascorbic acid demonstrated increased collagen and extracellular fibronectin synthesis in the treatment group (Skin Pharmacol. 1997;10:200-5).

Products

Like many herbal ingredients, ginkgo is used in a small but growing number of topical products. The Hydramax Ginkgo Biloba PhytoSerum (1 fl. oz./$15.50) is a moisturizer intended to restore chapped and severely dehydrated skin. The product is formulated with 2% standardized time-released phytoliposomes of G. biloba and buttressed by a cocktail of organic herb concentrates of white willow bark, ivy, comfrey, chamomile, mallow, and G. biloba as well as numerous emollient and essential oils in an organic aloe vera serum.

The Rejuvenex Body Lotion (6 oz./$21.60) features a highly purified alpha-glycolic acid, but includes ginkgo extract and vitamin E to protect against the skin irritation that high concentrations of glycolic acid can engender.

Ginkgo extract is increasingly found among the lists of the unadvertised or inactive ingredients in more and more topical skin care products. For example, two of the three products in the emerginC Crease Ease Kit ($250) – the emerginC crease ease emulsion (50 ml) and the emerginC crease ease gel (eye/lip area – 30 mL) – contain G. biloba along with a long list of other herbal ingredients.

Conclusion

Whether in oral or topical form, G. biloba extracts do not reek like the fruit of the tree; otherwise, such products might never make their way to the shelf. Use in aromatherapy would also be precluded. Fortunately, the offensive odor dissipates after separation of the nut from the seed shell and subsequent cleaning.

In topical products, various components of ginkgo are used more often as ancillary ingredients, though some formulations now feature this increasingly popular herbal ingredient. Preliminary research suggests reasons for optimism and should spur further investigation as to the overall health benefits conferred by G. biloba.

The research on vitiligo is particularly compelling from a dermatologic perspective. More study is required to ascertain whether topical formulations can harness the apparent antioxidant and anti-inflammatory effects to confer significant cutaneous benefits. More randomized controlled trials will build on what is currently a small but intriguing body of evidence.

In this month's program, Dr. Daniel E. Furst delivers tips for differentiating arthritis types in psoriasis patients with joint pain.

Dr. Thomas E. Rohrer shares the unveiling of the AAD's new prevention program: SPOT Skin Cancer.

Then, Dr. Lawrence F. Eichenfield discusses the first-ever acne treatment guidelines for children.

Cosmetic counter host Dr. Lily Talakoub explains how to talk to patients about the potentially toxic chemicals in their makeup bag.

And finally, Dr. Alan Rockoff explains why his young grandson doesn't want to be a "lotion" doctor.

In this month's program, Dr. Daniel E. Furst delivers tips for differentiating arthritis types in psoriasis patients with joint pain.

Dr. Thomas E. Rohrer shares the unveiling of the AAD's new prevention program: SPOT Skin Cancer.

Then, Dr. Lawrence F. Eichenfield discusses the first-ever acne treatment guidelines for children.

Cosmetic counter host Dr. Lily Talakoub explains how to talk to patients about the potentially toxic chemicals in their makeup bag.

And finally, Dr. Alan Rockoff explains why his young grandson doesn't want to be a "lotion" doctor.

In this month's program, Dr. Daniel E. Furst delivers tips for differentiating arthritis types in psoriasis patients with joint pain.

Dr. Thomas E. Rohrer shares the unveiling of the AAD's new prevention program: SPOT Skin Cancer.

Then, Dr. Lawrence F. Eichenfield discusses the first-ever acne treatment guidelines for children.

Cosmetic counter host Dr. Lily Talakoub explains how to talk to patients about the potentially toxic chemicals in their makeup bag.

And finally, Dr. Alan Rockoff explains why his young grandson doesn't want to be a "lotion" doctor.