Aesthetic Dermatology

NEW ORLEANS - Nonprescription skin care products formulated with a potent topical antioxidant resulted in objective improvement in prematurely aged skin in a small study of women aged 25 or older.

The antioxidant hydroxydecyl ubiquinoyl dipalmitoyl glycerate (idebenone complex) was incorporated in the skin care products to treat skin photodamage associated with cellular oxidative stress caused by reactive oxygen species, Dr. Michael H. Gold explained at the annual meeting of the American Academy of Dermatology.

He presented an open-label study involving 32 women aged 25-65 years with premature aging of the skin. Twice daily for 8 weeks they used test products containing 0.5% hydroxydecyl ubiquinoyl dipalmitoyl glycerate. Expert grading of various dimensions of skin quality was conducted at baseline and again at 4 and 8 weeks during physical examination and with the assistance of standardized photographs.

The skin care products consisted of a facial cleanser, a moisturizing cream, a skin brightener, and an eye serum. Study participants also used an SPF 30 sunscreen daily.

Skin roughness showed a mean 36% improvement at 8 weeks compared with baseline. Dyschromia also improved by an average of 36%, as did fine lines and wrinkles around the eyes. Skin radiance or glow improved by a mean of 44% over baseline. Skin brightness showed a 42% improvement. Skin tonality improved by an average of 41%, as did skin elasticity, determined by how fast the skin rebounds to the touch, reported Dr. Gold of the Tennessee Clinical Research Center, Nashville.

Overall global improvement was rated at a mean 42% gain, he added.

The study was sponsored by PCR Technology Holdings. Dr. Gold disclosed that he holds relevant intellectual property rights.

NEW ORLEANS - Nonprescription skin care products formulated with a potent topical antioxidant resulted in objective improvement in prematurely aged skin in a small study of women aged 25 or older.

The antioxidant hydroxydecyl ubiquinoyl dipalmitoyl glycerate (idebenone complex) was incorporated in the skin care products to treat skin photodamage associated with cellular oxidative stress caused by reactive oxygen species, Dr. Michael H. Gold explained at the annual meeting of the American Academy of Dermatology.

He presented an open-label study involving 32 women aged 25-65 years with premature aging of the skin. Twice daily for 8 weeks they used test products containing 0.5% hydroxydecyl ubiquinoyl dipalmitoyl glycerate. Expert grading of various dimensions of skin quality was conducted at baseline and again at 4 and 8 weeks during physical examination and with the assistance of standardized photographs.

The skin care products consisted of a facial cleanser, a moisturizing cream, a skin brightener, and an eye serum. Study participants also used an SPF 30 sunscreen daily.

Skin roughness showed a mean 36% improvement at 8 weeks compared with baseline. Dyschromia also improved by an average of 36%, as did fine lines and wrinkles around the eyes. Skin radiance or glow improved by a mean of 44% over baseline. Skin brightness showed a 42% improvement. Skin tonality improved by an average of 41%, as did skin elasticity, determined by how fast the skin rebounds to the touch, reported Dr. Gold of the Tennessee Clinical Research Center, Nashville.

Overall global improvement was rated at a mean 42% gain, he added.

The study was sponsored by PCR Technology Holdings. Dr. Gold disclosed that he holds relevant intellectual property rights.

NEW ORLEANS - Nonprescription skin care products formulated with a potent topical antioxidant resulted in objective improvement in prematurely aged skin in a small study of women aged 25 or older.

The antioxidant hydroxydecyl ubiquinoyl dipalmitoyl glycerate (idebenone complex) was incorporated in the skin care products to treat skin photodamage associated with cellular oxidative stress caused by reactive oxygen species, Dr. Michael H. Gold explained at the annual meeting of the American Academy of Dermatology.

He presented an open-label study involving 32 women aged 25-65 years with premature aging of the skin. Twice daily for 8 weeks they used test products containing 0.5% hydroxydecyl ubiquinoyl dipalmitoyl glycerate. Expert grading of various dimensions of skin quality was conducted at baseline and again at 4 and 8 weeks during physical examination and with the assistance of standardized photographs.

The skin care products consisted of a facial cleanser, a moisturizing cream, a skin brightener, and an eye serum. Study participants also used an SPF 30 sunscreen daily.

Skin roughness showed a mean 36% improvement at 8 weeks compared with baseline. Dyschromia also improved by an average of 36%, as did fine lines and wrinkles around the eyes. Skin radiance or glow improved by a mean of 44% over baseline. Skin brightness showed a 42% improvement. Skin tonality improved by an average of 41%, as did skin elasticity, determined by how fast the skin rebounds to the touch, reported Dr. Gold of the Tennessee Clinical Research Center, Nashville.

Overall global improvement was rated at a mean 42% gain, he added.

The study was sponsored by PCR Technology Holdings. Dr. Gold disclosed that he holds relevant intellectual property rights.

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

NEW ORLEANS - Lasers and photodynamic therapy for the treatment of fungal toenails are beginning to generate substantial buzz among patients and podiatrists, but key questions regarding these novel proposed device therapies remain to be answered before they can truly be said to be the future of onychomycosis therapy.

For laser therapy, these questions include "Does it actually work?" and if so, by what mechanism? Dr. Boni E. Elewski said at the annual meeting of the American Academy of Dermatology.

Interest in laser therapy for fungal nails took off when one device, the PinPointe FootLaser, received Food and Drug Administration clearance for onychomycosis last October. Of note, however, the FDA didn't clear the device as a curative therapy, but rather "for the temporary increase of clear nail in patients with onychomycosis." This hasn't stopped some podiatrists from offering treatment with the PinPointe or other neodymium:YAG 1,064-nm lasers at a price tag of up to $1,000 per toe, a marketing ploy that implies definitive therapy and prompted Dr. Elewski to take a closer look.

Her in vitro studies in the mycology lab have left her convinced that lasers don't eradicate fungi through heat killing; the required nail temperatures would be intolerably painful. Moreover, direct lasering of fungi on agar plates and dilute broth had absolutely no impact on fungal growth. But these negative studies don't rule out other potential mechanisms of action, including a possible immunologic effect or laser-induced denaturization of enzymes that fungi need to digest skin cells, noted Dr. Elewski, professor of dermatology at the University of Alabama at Birmingham.

She is now conducting a clinical study in which patients with onychomycosis are being treated with an Nd:YAG 1,064-nm laser – not the PinPointe FootLaser – with a 5-mm spot size, a frequency of 2 Hz, and an energy density of 16 J/cm². Patients get a total of five treatments, each consisting of more than 300 pulses administered over the nail during a couple of minutes in a predetermined pattern. Anecdotally, in individual patients she has observed instances of fungi evacuating laser-treated nails, and the nails becoming culture negative over a period of several months. The study, however, remains ongoing.

"The jury is still out. I can't say yet whether laser therapy works," Dr. Elewski commented.

Unlike laser therapy for onychomycosis, photodynamic therapy (PDT) is backed by a published rigorously conducted study. And the mechanism of action is understood: In vitro, Trichophyton rubrum absorbs 5-aminolevulinic acid and can be photo killed.

But onychomycosis is not an FDA-approved indication for PDT. Moreover, the results of the published study cited by Dr. Elewski – a 43% cure rate 12 months after PDT and 37% at 18 months of follow-up – are comparable to but not better than success rates attained in the major clinical trials of terbinafine. Plus, the PDT sessions must be preceded by a lengthy, labor-intensive chemical nail avulsion. Nonetheless, PDT may provide an alternative option for onychomycosis when terbinafine and other oral agents are contraindicated, she continued.

The PDT study involved 30 patients with onychomycosis resulting from Trichophyton rubrum who were treated at Aristotle University of Thessaloniki (Greece). Following 10 consecutive nights in which 20% urea ointment was applied under occlusion to the nail plate, dermatologists removed the nail with forceps and applied 20% 5-aminolevulinic acid for 3 hours before treatment with red light at 570-670 nm, a light density of 40 J/cm², and a fluence of 40 mW/cm². Patients got three treatment sessions, each 2 weeks apart.

The Greek investigators demanded a rigorous, FDA-style definition of cure: complete absence of clinical signs of fungal infection, or less than 10% of the nail being affected by subungual hyperkeratosis along with mycologic cure. Thirteen of 30 (43%) patients fulfilled this definition at 12 months, as did 11 (37%) at 18 months. No fungal resistance was seen (Acta Derm. Venereol. 2010;90:216-7).

Dr. Elewski said that she receives research support from Cutera.

Used for thousands of years for its emollient qualities, and for hundreds of years as an ingredient in skin care ointments, lanolin is a greasy yellow substance derived from the sebaceous secretions of sheep, as well as other wool-bearing animals (Br. J. Nurs. 2009:54-7). Although a plant-derived substitute has been recently produced, lanolin itself is a complex natural product that cannot be synthesized. It is also a commonly used occlusive ingredient, along with products or compounds such as paraffin, squalene, dimethicone, soybean oil, grapeseed oil, propylene glycol, and beeswax (Atlas of Cosmetic Dermatology, edited by Z. Draelos. New York: Churchill Livingstone, 2000, p. 83).

Photo courtesy USDA

Lanolin, like mineral oil and petrolatum, is known for it dual activity, exerting both occlusive and emollient effects. This column will briefly review the current status and reputation of lanolin as a cutaneous therapeutic agent.

Evidence of Contact Sensitization. Lanolin shares two important features with stratum corneum lipids: Lanolin contains cholesterol, an essential constituent of stratum corneum lipids; and lanolin and stratum corneum lipids can coexist as solids and liquids at physiologic temperatures. Not surprisingly, given its longtime use as an adjuvant, lanolin is characterized by a very different composition from human sebum. This is also the case for commercial lanolin products. Significantly, the method used to refine the compound determines the quality and composition of the resulting formulation; therefore, not all lanolin products exhibit the same activity (Dry Skin and Moisturizers, edited by M. Loden and H. Maibach. Boca Raton: CRC Press, 2000, p. 259).

Unfortunately, a small percentage of individuals who use lanolin develop contact sensitization to the occlusive/emollient agent. Consequently, lanolin has developed a reputation as a sensitizer that, according to some, may be undeserved (Contact Dermatitis 1998;39:103-7; Br. J. Nurs. 2000;26:54-7). Nevertheless, manufacturers have responded to such claims, and many moisturizing products are now touted as "lanolin free."

Another response to the notion that lanolin provokes allergic reactions has spurred the development of ultrapure, hypoallergenic, medical-grade lanolin formulations such as Medilan. In fact, Medilan has been shown to provoke virtually no sensitization (Br. J. Nurs. 2000;26;54-7). In addition to the soothing, healing properties imparted by Medilan, it is also effective as an occlusive agent and has exhibited the capacity to penetrate the skin and assist in stratum corneum water retention.

In 2008, investigators sought to identify the frequency of positive patch test reactions to common allergens in leg ulcer or venous disease patients by using a case series of 100 consecutive consenting subjects who had chronic venous disease and other leg ulcer etiologies. At least one positive patch test was observed in 46% of patients, with multiple reactions in the same subject frequently seen. Of the 38 common allergens tested, lanolin was identified among the most frequent sensitizers, which also included fragrances, antibacterial agents, and rubber-related compounds (Int. J. Low. Extrem. Wounds 2008;7:120-5). Of course, such results suggest that lanolin may be contraindicated in patients with leg ulcers, but are not generalizable to a healthy population.

Use in Nipple Crack and Xerosis. In 2003, Dodd and Chalmers led a multicenter, prospective, randomized controlled clinical trial to compare the effects of hydrogel dressings to lanolin ointment for the prevention and treatment of nipple soreness in 106 lactating mothers. A board-certified lactation specialist provided breastfeeding guidance at the beginning of the study. During the first 12 days of the study, participants, who were randomized to either of the two groups, were instructed to rate pain intensity according to a numeric scale as well as a verbal description scale. Patients then forwarded self-reported skin assessments of the bilateral breasts, nipples, and areolae to investigators.

A significantly greater reduction in pain score mean values was identified in the hydrogel group at baseline, day 10, and day 12, compared with the lanolin group, and the hydrogel group discontinued treatment earlier than did the participants using lanolin. Overall, researchers found hydrogel to be superior to lanolin ointment for the management of nipple soreness (J. Obstet. Gynecol. Neonatal Nurs. 2003;32:486-94).

Additional evidence that lanolin is not the optimal therapeutic option for sore or cracked nipples came 4 years later, when investigators conducted a randomized, double-blind clinical trial to compare a peppermint gel formulation, modified lanolin, and a placebo control ointment for the treatment of nipple crack related to breastfeeding. A total of 216 primiparous mothers were randomly assigned to the three groups, which were comparable in mean age, and were instructed to apply their selected formulation on both breasts for 14 days. Patients were seen for up to four follow-up visits, as well as a final visit at week 6. Researchers found that nipple and areola cracks were less frequent in the peppermint gel group than in the lanolin group or placebo group (Med. Sci. Monit. 2007;13:CR406-11).

Nonetheless, such results do not detract from the appropriateness of lanolin for other dry skin indications. Notably, in 2003, investigators conducted a 4-week double-blind, randomized-comparison clinical trial to assess the effectiveness of pure lanolin, compared with ammonium lactate 12% cream in the treatment of moderate to severe xerosis on the feet. Of the original 92 patients enrolled, 51 completed the study. Both treatment groups exhibited significant improvement in xerosis scores after 2 and 4 weeks of treatment, with no statistically significant differences identified between the groups. The researchers concluded that pure lanolin as well as ammonium lactate cream used twice daily for a month were effective in ameliorating moderate to severe dry skin (Cutis 2003;71:78-82).

In 2008, researchers reported on a comparison of two different topical ointments used in cutaneous therapy on 173 prospectively enrolled infants born between 25 and 36 weeks of gestation. The infants were admitted to a neonatal intensive care unit between October 2004 and November 2006. Each infant was treated for up to 4 weeks after being randomly assigned to daily treatment with water-in-oil emollient cream (Bepanthen), olive oil cream (70% lanolin, 30% olive oil), or a topical control. Skin was assessed weekly. The investigators found that while both treatment groups displayed greater improvement than the control group, with enduring treatment effects, infants in the lanolin/olive oil group exhibited significantly less dermatitis than did those in the water-in-oil emollient group (Pediatr. Dermatol. 2008;25:174-8).

It is also worth acknowledging that scientists at Nippon Fine Chemicals, Tokyo, announced in 2006 that they had developed a plant-derived lanolin or adsorption-refined lanolin substitute (bis-beheyl/isostearyl/phytosteryl dimer dilinoleyl dimer dilinoleate). This phytosterol ester (an oligomer ester) is noted for its pale color, mild odor, superlative stability, moisturizing effects in human tests, and lanolin-like water-retention capacity (200%). Researchers for the company claim that this oligomer ester is suitable for inclusion in skin and hair care products, makeup, and cleansing formulations (J. Cosmet .Sci. 2006;57:193-4). Indeed, traditional lanolin is found in various cosmetic products, such as facial lotions, body washes, foot creams, hair care products, lipsticks, and lip balms.

Conclusion. Through the last several decades, only a small proportion of the population has been found to be allergic to lanolin. Significantly, allergic responses have not been reported with the use of more modern, medical-grade and other highly refined lanolin products. It is worth mentioning these facts to patients with dry skin who may benefit from using lanolin but who offer objections simply because they heard that it may induce allergic reactions.

To patients who may object because of the animal origin of the substance, it is important to at least mitigate this argument by mentioning that while lanolin is secreted by the sebaceous glands of sheep and then obtained from their shorn wool and refined, the process is conducted without harming the animal. Lanolin, particularly in the more recent formulations, is an effective first-line occlusive and emollient agent option for various xerotic conditions.

Used for thousands of years for its emollient qualities, and for hundreds of years as an ingredient in skin care ointments, lanolin is a greasy yellow substance derived from the sebaceous secretions of sheep, as well as other wool-bearing animals (Br. J. Nurs. 2009:54-7). Although a plant-derived substitute has been recently produced, lanolin itself is a complex natural product that cannot be synthesized. It is also a commonly used occlusive ingredient, along with products or compounds such as paraffin, squalene, dimethicone, soybean oil, grapeseed oil, propylene glycol, and beeswax (Atlas of Cosmetic Dermatology, edited by Z. Draelos. New York: Churchill Livingstone, 2000, p. 83).

Photo courtesy USDA

Lanolin, like mineral oil and petrolatum, is known for it dual activity, exerting both occlusive and emollient effects. This column will briefly review the current status and reputation of lanolin as a cutaneous therapeutic agent.

Evidence of Contact Sensitization. Lanolin shares two important features with stratum corneum lipids: Lanolin contains cholesterol, an essential constituent of stratum corneum lipids; and lanolin and stratum corneum lipids can coexist as solids and liquids at physiologic temperatures. Not surprisingly, given its longtime use as an adjuvant, lanolin is characterized by a very different composition from human sebum. This is also the case for commercial lanolin products. Significantly, the method used to refine the compound determines the quality and composition of the resulting formulation; therefore, not all lanolin products exhibit the same activity (Dry Skin and Moisturizers, edited by M. Loden and H. Maibach. Boca Raton: CRC Press, 2000, p. 259).

Unfortunately, a small percentage of individuals who use lanolin develop contact sensitization to the occlusive/emollient agent. Consequently, lanolin has developed a reputation as a sensitizer that, according to some, may be undeserved (Contact Dermatitis 1998;39:103-7; Br. J. Nurs. 2000;26:54-7). Nevertheless, manufacturers have responded to such claims, and many moisturizing products are now touted as "lanolin free."

Another response to the notion that lanolin provokes allergic reactions has spurred the development of ultrapure, hypoallergenic, medical-grade lanolin formulations such as Medilan. In fact, Medilan has been shown to provoke virtually no sensitization (Br. J. Nurs. 2000;26;54-7). In addition to the soothing, healing properties imparted by Medilan, it is also effective as an occlusive agent and has exhibited the capacity to penetrate the skin and assist in stratum corneum water retention.

In 2008, investigators sought to identify the frequency of positive patch test reactions to common allergens in leg ulcer or venous disease patients by using a case series of 100 consecutive consenting subjects who had chronic venous disease and other leg ulcer etiologies. At least one positive patch test was observed in 46% of patients, with multiple reactions in the same subject frequently seen. Of the 38 common allergens tested, lanolin was identified among the most frequent sensitizers, which also included fragrances, antibacterial agents, and rubber-related compounds (Int. J. Low. Extrem. Wounds 2008;7:120-5). Of course, such results suggest that lanolin may be contraindicated in patients with leg ulcers, but are not generalizable to a healthy population.

Use in Nipple Crack and Xerosis. In 2003, Dodd and Chalmers led a multicenter, prospective, randomized controlled clinical trial to compare the effects of hydrogel dressings to lanolin ointment for the prevention and treatment of nipple soreness in 106 lactating mothers. A board-certified lactation specialist provided breastfeeding guidance at the beginning of the study. During the first 12 days of the study, participants, who were randomized to either of the two groups, were instructed to rate pain intensity according to a numeric scale as well as a verbal description scale. Patients then forwarded self-reported skin assessments of the bilateral breasts, nipples, and areolae to investigators.

A significantly greater reduction in pain score mean values was identified in the hydrogel group at baseline, day 10, and day 12, compared with the lanolin group, and the hydrogel group discontinued treatment earlier than did the participants using lanolin. Overall, researchers found hydrogel to be superior to lanolin ointment for the management of nipple soreness (J. Obstet. Gynecol. Neonatal Nurs. 2003;32:486-94).

Additional evidence that lanolin is not the optimal therapeutic option for sore or cracked nipples came 4 years later, when investigators conducted a randomized, double-blind clinical trial to compare a peppermint gel formulation, modified lanolin, and a placebo control ointment for the treatment of nipple crack related to breastfeeding. A total of 216 primiparous mothers were randomly assigned to the three groups, which were comparable in mean age, and were instructed to apply their selected formulation on both breasts for 14 days. Patients were seen for up to four follow-up visits, as well as a final visit at week 6. Researchers found that nipple and areola cracks were less frequent in the peppermint gel group than in the lanolin group or placebo group (Med. Sci. Monit. 2007;13:CR406-11).

Nonetheless, such results do not detract from the appropriateness of lanolin for other dry skin indications. Notably, in 2003, investigators conducted a 4-week double-blind, randomized-comparison clinical trial to assess the effectiveness of pure lanolin, compared with ammonium lactate 12% cream in the treatment of moderate to severe xerosis on the feet. Of the original 92 patients enrolled, 51 completed the study. Both treatment groups exhibited significant improvement in xerosis scores after 2 and 4 weeks of treatment, with no statistically significant differences identified between the groups. The researchers concluded that pure lanolin as well as ammonium lactate cream used twice daily for a month were effective in ameliorating moderate to severe dry skin (Cutis 2003;71:78-82).

In 2008, researchers reported on a comparison of two different topical ointments used in cutaneous therapy on 173 prospectively enrolled infants born between 25 and 36 weeks of gestation. The infants were admitted to a neonatal intensive care unit between October 2004 and November 2006. Each infant was treated for up to 4 weeks after being randomly assigned to daily treatment with water-in-oil emollient cream (Bepanthen), olive oil cream (70% lanolin, 30% olive oil), or a topical control. Skin was assessed weekly. The investigators found that while both treatment groups displayed greater improvement than the control group, with enduring treatment effects, infants in the lanolin/olive oil group exhibited significantly less dermatitis than did those in the water-in-oil emollient group (Pediatr. Dermatol. 2008;25:174-8).

It is also worth acknowledging that scientists at Nippon Fine Chemicals, Tokyo, announced in 2006 that they had developed a plant-derived lanolin or adsorption-refined lanolin substitute (bis-beheyl/isostearyl/phytosteryl dimer dilinoleyl dimer dilinoleate). This phytosterol ester (an oligomer ester) is noted for its pale color, mild odor, superlative stability, moisturizing effects in human tests, and lanolin-like water-retention capacity (200%). Researchers for the company claim that this oligomer ester is suitable for inclusion in skin and hair care products, makeup, and cleansing formulations (J. Cosmet .Sci. 2006;57:193-4). Indeed, traditional lanolin is found in various cosmetic products, such as facial lotions, body washes, foot creams, hair care products, lipsticks, and lip balms.

Conclusion. Through the last several decades, only a small proportion of the population has been found to be allergic to lanolin. Significantly, allergic responses have not been reported with the use of more modern, medical-grade and other highly refined lanolin products. It is worth mentioning these facts to patients with dry skin who may benefit from using lanolin but who offer objections simply because they heard that it may induce allergic reactions.

To patients who may object because of the animal origin of the substance, it is important to at least mitigate this argument by mentioning that while lanolin is secreted by the sebaceous glands of sheep and then obtained from their shorn wool and refined, the process is conducted without harming the animal. Lanolin, particularly in the more recent formulations, is an effective first-line occlusive and emollient agent option for various xerotic conditions.

Used for thousands of years for its emollient qualities, and for hundreds of years as an ingredient in skin care ointments, lanolin is a greasy yellow substance derived from the sebaceous secretions of sheep, as well as other wool-bearing animals (Br. J. Nurs. 2009:54-7). Although a plant-derived substitute has been recently produced, lanolin itself is a complex natural product that cannot be synthesized. It is also a commonly used occlusive ingredient, along with products or compounds such as paraffin, squalene, dimethicone, soybean oil, grapeseed oil, propylene glycol, and beeswax (Atlas of Cosmetic Dermatology, edited by Z. Draelos. New York: Churchill Livingstone, 2000, p. 83).

Photo courtesy USDA

Lanolin, like mineral oil and petrolatum, is known for it dual activity, exerting both occlusive and emollient effects. This column will briefly review the current status and reputation of lanolin as a cutaneous therapeutic agent.

Evidence of Contact Sensitization. Lanolin shares two important features with stratum corneum lipids: Lanolin contains cholesterol, an essential constituent of stratum corneum lipids; and lanolin and stratum corneum lipids can coexist as solids and liquids at physiologic temperatures. Not surprisingly, given its longtime use as an adjuvant, lanolin is characterized by a very different composition from human sebum. This is also the case for commercial lanolin products. Significantly, the method used to refine the compound determines the quality and composition of the resulting formulation; therefore, not all lanolin products exhibit the same activity (Dry Skin and Moisturizers, edited by M. Loden and H. Maibach. Boca Raton: CRC Press, 2000, p. 259).

Unfortunately, a small percentage of individuals who use lanolin develop contact sensitization to the occlusive/emollient agent. Consequently, lanolin has developed a reputation as a sensitizer that, according to some, may be undeserved (Contact Dermatitis 1998;39:103-7; Br. J. Nurs. 2000;26:54-7). Nevertheless, manufacturers have responded to such claims, and many moisturizing products are now touted as "lanolin free."

Another response to the notion that lanolin provokes allergic reactions has spurred the development of ultrapure, hypoallergenic, medical-grade lanolin formulations such as Medilan. In fact, Medilan has been shown to provoke virtually no sensitization (Br. J. Nurs. 2000;26;54-7). In addition to the soothing, healing properties imparted by Medilan, it is also effective as an occlusive agent and has exhibited the capacity to penetrate the skin and assist in stratum corneum water retention.

In 2008, investigators sought to identify the frequency of positive patch test reactions to common allergens in leg ulcer or venous disease patients by using a case series of 100 consecutive consenting subjects who had chronic venous disease and other leg ulcer etiologies. At least one positive patch test was observed in 46% of patients, with multiple reactions in the same subject frequently seen. Of the 38 common allergens tested, lanolin was identified among the most frequent sensitizers, which also included fragrances, antibacterial agents, and rubber-related compounds (Int. J. Low. Extrem. Wounds 2008;7:120-5). Of course, such results suggest that lanolin may be contraindicated in patients with leg ulcers, but are not generalizable to a healthy population.

Use in Nipple Crack and Xerosis. In 2003, Dodd and Chalmers led a multicenter, prospective, randomized controlled clinical trial to compare the effects of hydrogel dressings to lanolin ointment for the prevention and treatment of nipple soreness in 106 lactating mothers. A board-certified lactation specialist provided breastfeeding guidance at the beginning of the study. During the first 12 days of the study, participants, who were randomized to either of the two groups, were instructed to rate pain intensity according to a numeric scale as well as a verbal description scale. Patients then forwarded self-reported skin assessments of the bilateral breasts, nipples, and areolae to investigators.

A significantly greater reduction in pain score mean values was identified in the hydrogel group at baseline, day 10, and day 12, compared with the lanolin group, and the hydrogel group discontinued treatment earlier than did the participants using lanolin. Overall, researchers found hydrogel to be superior to lanolin ointment for the management of nipple soreness (J. Obstet. Gynecol. Neonatal Nurs. 2003;32:486-94).

Additional evidence that lanolin is not the optimal therapeutic option for sore or cracked nipples came 4 years later, when investigators conducted a randomized, double-blind clinical trial to compare a peppermint gel formulation, modified lanolin, and a placebo control ointment for the treatment of nipple crack related to breastfeeding. A total of 216 primiparous mothers were randomly assigned to the three groups, which were comparable in mean age, and were instructed to apply their selected formulation on both breasts for 14 days. Patients were seen for up to four follow-up visits, as well as a final visit at week 6. Researchers found that nipple and areola cracks were less frequent in the peppermint gel group than in the lanolin group or placebo group (Med. Sci. Monit. 2007;13:CR406-11).

Nonetheless, such results do not detract from the appropriateness of lanolin for other dry skin indications. Notably, in 2003, investigators conducted a 4-week double-blind, randomized-comparison clinical trial to assess the effectiveness of pure lanolin, compared with ammonium lactate 12% cream in the treatment of moderate to severe xerosis on the feet. Of the original 92 patients enrolled, 51 completed the study. Both treatment groups exhibited significant improvement in xerosis scores after 2 and 4 weeks of treatment, with no statistically significant differences identified between the groups. The researchers concluded that pure lanolin as well as ammonium lactate cream used twice daily for a month were effective in ameliorating moderate to severe dry skin (Cutis 2003;71:78-82).

In 2008, researchers reported on a comparison of two different topical ointments used in cutaneous therapy on 173 prospectively enrolled infants born between 25 and 36 weeks of gestation. The infants were admitted to a neonatal intensive care unit between October 2004 and November 2006. Each infant was treated for up to 4 weeks after being randomly assigned to daily treatment with water-in-oil emollient cream (Bepanthen), olive oil cream (70% lanolin, 30% olive oil), or a topical control. Skin was assessed weekly. The investigators found that while both treatment groups displayed greater improvement than the control group, with enduring treatment effects, infants in the lanolin/olive oil group exhibited significantly less dermatitis than did those in the water-in-oil emollient group (Pediatr. Dermatol. 2008;25:174-8).

It is also worth acknowledging that scientists at Nippon Fine Chemicals, Tokyo, announced in 2006 that they had developed a plant-derived lanolin or adsorption-refined lanolin substitute (bis-beheyl/isostearyl/phytosteryl dimer dilinoleyl dimer dilinoleate). This phytosterol ester (an oligomer ester) is noted for its pale color, mild odor, superlative stability, moisturizing effects in human tests, and lanolin-like water-retention capacity (200%). Researchers for the company claim that this oligomer ester is suitable for inclusion in skin and hair care products, makeup, and cleansing formulations (J. Cosmet .Sci. 2006;57:193-4). Indeed, traditional lanolin is found in various cosmetic products, such as facial lotions, body washes, foot creams, hair care products, lipsticks, and lip balms.

Conclusion. Through the last several decades, only a small proportion of the population has been found to be allergic to lanolin. Significantly, allergic responses have not been reported with the use of more modern, medical-grade and other highly refined lanolin products. It is worth mentioning these facts to patients with dry skin who may benefit from using lanolin but who offer objections simply because they heard that it may induce allergic reactions.

To patients who may object because of the animal origin of the substance, it is important to at least mitigate this argument by mentioning that while lanolin is secreted by the sebaceous glands of sheep and then obtained from their shorn wool and refined, the process is conducted without harming the animal. Lanolin, particularly in the more recent formulations, is an effective first-line occlusive and emollient agent option for various xerotic conditions.

Interest in cosmetic surgery is increasing as consumers gain confidence in the economy, according to the American Society of Plastic Surgeons.

New statistics from the ASPS show that 13.1 million cosmetic plastic surgery procedures were performed in the United States last year, an increase of 5% over 2009. The increase reflects growth in both surgical procedures such as breast augmentation and minimally-invasive procedures such as injections of Botulinum toxin type A and soft-tissue fillers.

Photo (c) DenGuy/iStock.com

The ASPS statistics come from an annual survey of 747 physicians who perform cosmetic procedures, as well as an online national database for plastic surgery procedures.

"There's some pent up demand for cosmetic surgical procedures," Dr. Phillip Haeck, ASPS president, said in a statement. "People have waited a couple of years or more to have procedures, until their finances were at least somewhat back in order. But all indications are [that] more consumers are again willing to spend more to look better."

There are a number of factors potentially driving the increase in cosmetic surgery, Dr. Haeck said, from the improved economy to aging baby boomers seeking aesthetic procedures to stay competitive in the workplace.

Minimally-invasive cosmetic procedures showed the biggest increases in 2010 with nearly 11.6 million procedures performed, up from about 11 million the previous year. As in previous years, Botulinum toxin type A led the pack with 5.4 million procedures. Soft-tissue fillers were also popular with 1.8 million procedures. Rounding out the top five minimally-invasive procedures in 2010 were chemical peels, laser hair removal, and microdermabrasion.

"Injectables have remained robust despite the economy," Dr. Haeck said. "Botox and Dysport injections are up 12%, while, interestingly, fat injections are up 14%, which could reflect how a patient's own fat is being used in more creative ways to rejuvenate the face and body."

While the number of surgical procedures increased in 2010, the same types of procedures remained popular. The top five surgical procedures in 2010 were breast augmentation, rhinoplasty, eyelid surgery, liposuction, and abdominoplasty.

The ASPS also reported figures on reconstructive plastic surgery procedures. In 2010, more than 5.3 million reconstructive procedures were performed, up 2% from the previous year. Tumor removal led the list with 4 million procedures. Laceration repair, scar revision, hand surgery, and breast reconstruction were also in the top five.

Interest in cosmetic surgery is increasing as consumers gain confidence in the economy, according to the American Society of Plastic Surgeons.

New statistics from the ASPS show that 13.1 million cosmetic plastic surgery procedures were performed in the United States last year, an increase of 5% over 2009. The increase reflects growth in both surgical procedures such as breast augmentation and minimally-invasive procedures such as injections of Botulinum toxin type A and soft-tissue fillers.

Photo (c) DenGuy/iStock.com

The ASPS statistics come from an annual survey of 747 physicians who perform cosmetic procedures, as well as an online national database for plastic surgery procedures.

"There's some pent up demand for cosmetic surgical procedures," Dr. Phillip Haeck, ASPS president, said in a statement. "People have waited a couple of years or more to have procedures, until their finances were at least somewhat back in order. But all indications are [that] more consumers are again willing to spend more to look better."

There are a number of factors potentially driving the increase in cosmetic surgery, Dr. Haeck said, from the improved economy to aging baby boomers seeking aesthetic procedures to stay competitive in the workplace.

Minimally-invasive cosmetic procedures showed the biggest increases in 2010 with nearly 11.6 million procedures performed, up from about 11 million the previous year. As in previous years, Botulinum toxin type A led the pack with 5.4 million procedures. Soft-tissue fillers were also popular with 1.8 million procedures. Rounding out the top five minimally-invasive procedures in 2010 were chemical peels, laser hair removal, and microdermabrasion.

"Injectables have remained robust despite the economy," Dr. Haeck said. "Botox and Dysport injections are up 12%, while, interestingly, fat injections are up 14%, which could reflect how a patient's own fat is being used in more creative ways to rejuvenate the face and body."

While the number of surgical procedures increased in 2010, the same types of procedures remained popular. The top five surgical procedures in 2010 were breast augmentation, rhinoplasty, eyelid surgery, liposuction, and abdominoplasty.

The ASPS also reported figures on reconstructive plastic surgery procedures. In 2010, more than 5.3 million reconstructive procedures were performed, up 2% from the previous year. Tumor removal led the list with 4 million procedures. Laceration repair, scar revision, hand surgery, and breast reconstruction were also in the top five.

Interest in cosmetic surgery is increasing as consumers gain confidence in the economy, according to the American Society of Plastic Surgeons.

New statistics from the ASPS show that 13.1 million cosmetic plastic surgery procedures were performed in the United States last year, an increase of 5% over 2009. The increase reflects growth in both surgical procedures such as breast augmentation and minimally-invasive procedures such as injections of Botulinum toxin type A and soft-tissue fillers.

Photo (c) DenGuy/iStock.com

The ASPS statistics come from an annual survey of 747 physicians who perform cosmetic procedures, as well as an online national database for plastic surgery procedures.

"There's some pent up demand for cosmetic surgical procedures," Dr. Phillip Haeck, ASPS president, said in a statement. "People have waited a couple of years or more to have procedures, until their finances were at least somewhat back in order. But all indications are [that] more consumers are again willing to spend more to look better."

There are a number of factors potentially driving the increase in cosmetic surgery, Dr. Haeck said, from the improved economy to aging baby boomers seeking aesthetic procedures to stay competitive in the workplace.

Minimally-invasive cosmetic procedures showed the biggest increases in 2010 with nearly 11.6 million procedures performed, up from about 11 million the previous year. As in previous years, Botulinum toxin type A led the pack with 5.4 million procedures. Soft-tissue fillers were also popular with 1.8 million procedures. Rounding out the top five minimally-invasive procedures in 2010 were chemical peels, laser hair removal, and microdermabrasion.

"Injectables have remained robust despite the economy," Dr. Haeck said. "Botox and Dysport injections are up 12%, while, interestingly, fat injections are up 14%, which could reflect how a patient's own fat is being used in more creative ways to rejuvenate the face and body."

While the number of surgical procedures increased in 2010, the same types of procedures remained popular. The top five surgical procedures in 2010 were breast augmentation, rhinoplasty, eyelid surgery, liposuction, and abdominoplasty.

The ASPS also reported figures on reconstructive plastic surgery procedures. In 2010, more than 5.3 million reconstructive procedures were performed, up 2% from the previous year. Tumor removal led the list with 4 million procedures. Laceration repair, scar revision, hand surgery, and breast reconstruction were also in the top five.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

ORLANDO – "The diameter of a single hair shaft is tens of thousands of nanometers," said Dr. Adam Friedman. Nanotechnology is the branch of technology related to dimensions and tolerances ranging from 0.1 to 100 nanometers.

"At this size, matter behaves somewhat differently," Dr. Friedman, of Albert Einstein College of Medicine in New York, said. As the size of material decreases, the surface area relative to volume decreases. There is more surface to interact with the environment.

"The three properties of matter – chemical, optical, and physical – can be manipulated and exploited at the nano scale," Dr. Friedman said. For example, something that is too bulky at the macro level to go into an aqueous vehicle can be distributed more easily in nano form. And "if something is smaller than the wavelength of visible light, guess what? It is going to be invisible," he said at the Orlando Dermatology Aesthetic and Clinical Conference.

By the year 2012, nanotechnology is predicted to be a $12 billion industry in the United States, and the cosmetic and cosmeceutical industries are leading the way, Dr. Friedman noted. He discussed several nanomaterials with diagnostic and therapeutic applications for dermatologists:

• Nanoparticles. The term nanoparticle is somewhat generic, Dr. Friedman said. The term refers to a small object that behaves as a whole unit in terms of its transport and properties. Nanoparticles can be derived from organic and nonorganic materials. For example, gold nanoparticles can be used to introduce an antibody or targeting molecule into the body to target tumors. Once the tumors are bound to the gold, they can be treated using selective photolysis, in which radiation is used to heat the gold enough to kill the tumor cells. In one study of mice, hollow gold nanoparticles were used to successfully treat melanoma, said Dr. Friedman. Silver nanoparticles are already in products ranging from clothing to plastic food storage containers, to take advantage of their antimicrobial properties, he said.

• Nanoemulsions. Nanoemulsions are already widely used in dermatology, in emollients, and as delivery vehicles for antiaging products. Nanoemulsions have an appealing nongreasy texture, are invisible, and penetrate the skin rapidly, Dr. Friedman said. Nanoemulsion products currently on the market include L’Oréal Plenitude Revitalift and Caudalie Vinosun Anti-Aging Suncare.

• Quantum dots. "These highly fluorescent nanoscale crystals absorb a broad range of wavelengths; however, they only re-emit one color," said Dr. Friedman. In dermatology, quantum dots are being used to identify sentinel lymph nodes in patients with melanoma and Merkel cell carcinoma.

• Nanomagnets. Nanosized magnetic materials "no longer exhibit a net magnetic force," Dr. Friedman said. These materials could be used to create magnetic field–directed imaging or therapy.

• Nanopigments. Many currently available sunblocks include nanoparticles of titanium or zinc oxide, such as SunVex Dailywear lotions and ZinClear Nano Zinc Oxide.

About safety: "From a purely theoretical standpoint, nanoparticles should be harmful," said Dr. Friedman. The same properties that make nanoparticles useful could come with side effects. Improved skin penetration can be beneficial for dermatology, but factors that determine the potential toxicity of nanoparticles include size, chemical purity, and the activity of the surface.

The current international stance on nanoparticle safety is that it is unlikely that significant amounts of the zinc or titanium used in sunblock products will result in local or systemic toxicity. However, "the safety of nanoscale zinc and titanium in sunscreen must be fully addressed," Dr. Friedman said. In 2009, the American Academy of Dermatology established a task force to study nanotechnology and educate the dermatology community, the public, and policy makers.

Dermatologists who are intrigued by the potential of nanotechnology can join the fledgling Nanodermatology Society, which had its first meeting for the 2011 AAD annual meeting in New Orleans. For more information, visit the society's Web site at www.nanodermsociety.org.

Dr. Friedman serves on the advisory board of Makefield Therapeutics.

NEW ORLEANS - Even if you don't use lasers in your day-to-day practice of dermatology, it's helpful to know the options and their limitations to prevent unnecessary referrals, Dr. Harvey Lui said.

"For those of you who do not use lasers, hopefully you can learn which things those of us who do lasers can help you with and things we cannot," Dr. Lui said at the annual meeting of the American Academy of Dermatology.

If the question is whether to use laser treatment for pigmentation disorders, the answers vary from yes to maybe to no.

As a general guide, the depth of the dyspigmentation makes the difference with lasers, so Dr. Lui addressed their use for epidermal, mixed epidermal-dermal, or dermal disorders.

Epidermal Dyspigmentation. Lentigines are the prototype epidermal pigmentation disorder. "Lasers are highly effective, relatively simple, [and work in] one to two treatments," Dr. Lui said. Although lasers are not the only treatment option (for example, there is cryotherapy), "I get more precise effects in my practice for darker-skinned patients."

Lasers are also useful to treat a seborrheic keratosis. The advantage with lasers is an ability to target each spot to be cleared, Dr. Lui said.

In contrast, a Becker's nevus does not respond very well to laser treatment, "even though pigmentation is right there in the epidermis just begging to be removed," said Dr. Lui, medical director of the Skin Care Centre and head of the department of dermatology and skin science at the University of British Columbia, Vancouver. "There was some initial excitement using fractional photothermolysis, but I don't think that has panned out over time."

Lasers are not ideal for an epidermal nevus either, Dr. Lui said, due to a higher recurrence rate. However, he added, "in a highly motivated patient, I might do a test spot first."

A high recurrence rate and an unpredictable response are reasons to avoid laser treatment for café au lait macules, Dr. Lui said. Smaller lesions tend to respond the best. He advised caution, because there can be some paradoxical darkening in these patients.

Mixed Epidermal-Dermal Dyspigmentation. Expect a variable response to lasers for melanocytic nevi. "The best response is with small, junctional nevi." Use the highest fluence possible, Dr. Lui advised. An unknown long-term risk and incomplete pigment removal that can lead to problematic lesions are considerations. "Tell the patient that if the pigment does not completely clear, we are going to cut it out. You don't want to leave them with a lesion that meets one of the ABCD criteria [that could develop into melanoma someday]," Dr. Lui said.

Congenital melanocytic nevi may respond to a normal-mode ruby laser, but again, the long-term risk is unknown.

Dr. Lui generally does not recommend lasers for melasma. "The bottom line is that melasma will reliably darken with lasers. You can bet on it." Initial excitement about fractional lasers did not pan out, he added.

Dr. Lui also cautioned against lasers for postinflammatory hyperpigmentation. "A laser usually generates more postinflammatory hyperpigmentation. It's just a vicious circle, so the bottom line is 'Don't go there.' " Instead, convince your patient to be patient. "The best treatment is often time, and it's the cheapest, too."

Dermal Dyspigmentation. Nevus of Ota and nevus of Ito, which are more common in Asian patients, feature an excellent responsiveness to laser treatment, Dr. Lui said. "These are life-transforming types of procedures you can do for patients. This is why I became a doctor."

Lasers also are appropriate for treatment of Hori's macules. These often look like lentigines, Dr. Lui said. To distinguish between the two types of lesions, look for a blue-gray color (as opposed to a brown color with lentigines) and lesions that appear smudgy rather than well delineated.

Lasers can be used to treat blue nevi, but caution is advised, Dr. Lui said.

Dr. Lui said that he had no relevant financial disclosures.

NEW ORLEANS - Even if you don't use lasers in your day-to-day practice of dermatology, it's helpful to know the options and their limitations to prevent unnecessary referrals, Dr. Harvey Lui said.

"For those of you who do not use lasers, hopefully you can learn which things those of us who do lasers can help you with and things we cannot," Dr. Lui said at the annual meeting of the American Academy of Dermatology.

If the question is whether to use laser treatment for pigmentation disorders, the answers vary from yes to maybe to no.

As a general guide, the depth of the dyspigmentation makes the difference with lasers, so Dr. Lui addressed their use for epidermal, mixed epidermal-dermal, or dermal disorders.

Epidermal Dyspigmentation. Lentigines are the prototype epidermal pigmentation disorder. "Lasers are highly effective, relatively simple, [and work in] one to two treatments," Dr. Lui said. Although lasers are not the only treatment option (for example, there is cryotherapy), "I get more precise effects in my practice for darker-skinned patients."

Lasers are also useful to treat a seborrheic keratosis. The advantage with lasers is an ability to target each spot to be cleared, Dr. Lui said.

In contrast, a Becker's nevus does not respond very well to laser treatment, "even though pigmentation is right there in the epidermis just begging to be removed," said Dr. Lui, medical director of the Skin Care Centre and head of the department of dermatology and skin science at the University of British Columbia, Vancouver. "There was some initial excitement using fractional photothermolysis, but I don't think that has panned out over time."

Lasers are not ideal for an epidermal nevus either, Dr. Lui said, due to a higher recurrence rate. However, he added, "in a highly motivated patient, I might do a test spot first."

A high recurrence rate and an unpredictable response are reasons to avoid laser treatment for café au lait macules, Dr. Lui said. Smaller lesions tend to respond the best. He advised caution, because there can be some paradoxical darkening in these patients.

Mixed Epidermal-Dermal Dyspigmentation. Expect a variable response to lasers for melanocytic nevi. "The best response is with small, junctional nevi." Use the highest fluence possible, Dr. Lui advised. An unknown long-term risk and incomplete pigment removal that can lead to problematic lesions are considerations. "Tell the patient that if the pigment does not completely clear, we are going to cut it out. You don't want to leave them with a lesion that meets one of the ABCD criteria [that could develop into melanoma someday]," Dr. Lui said.

Congenital melanocytic nevi may respond to a normal-mode ruby laser, but again, the long-term risk is unknown.

Dr. Lui generally does not recommend lasers for melasma. "The bottom line is that melasma will reliably darken with lasers. You can bet on it." Initial excitement about fractional lasers did not pan out, he added.

Dr. Lui also cautioned against lasers for postinflammatory hyperpigmentation. "A laser usually generates more postinflammatory hyperpigmentation. It's just a vicious circle, so the bottom line is 'Don't go there.' " Instead, convince your patient to be patient. "The best treatment is often time, and it's the cheapest, too."

Dermal Dyspigmentation. Nevus of Ota and nevus of Ito, which are more common in Asian patients, feature an excellent responsiveness to laser treatment, Dr. Lui said. "These are life-transforming types of procedures you can do for patients. This is why I became a doctor."

Lasers also are appropriate for treatment of Hori's macules. These often look like lentigines, Dr. Lui said. To distinguish between the two types of lesions, look for a blue-gray color (as opposed to a brown color with lentigines) and lesions that appear smudgy rather than well delineated.

Lasers can be used to treat blue nevi, but caution is advised, Dr. Lui said.

Dr. Lui said that he had no relevant financial disclosures.

NEW ORLEANS - Even if you don't use lasers in your day-to-day practice of dermatology, it's helpful to know the options and their limitations to prevent unnecessary referrals, Dr. Harvey Lui said.

"For those of you who do not use lasers, hopefully you can learn which things those of us who do lasers can help you with and things we cannot," Dr. Lui said at the annual meeting of the American Academy of Dermatology.

If the question is whether to use laser treatment for pigmentation disorders, the answers vary from yes to maybe to no.

As a general guide, the depth of the dyspigmentation makes the difference with lasers, so Dr. Lui addressed their use for epidermal, mixed epidermal-dermal, or dermal disorders.

Epidermal Dyspigmentation. Lentigines are the prototype epidermal pigmentation disorder. "Lasers are highly effective, relatively simple, [and work in] one to two treatments," Dr. Lui said. Although lasers are not the only treatment option (for example, there is cryotherapy), "I get more precise effects in my practice for darker-skinned patients."

Lasers are also useful to treat a seborrheic keratosis. The advantage with lasers is an ability to target each spot to be cleared, Dr. Lui said.

In contrast, a Becker's nevus does not respond very well to laser treatment, "even though pigmentation is right there in the epidermis just begging to be removed," said Dr. Lui, medical director of the Skin Care Centre and head of the department of dermatology and skin science at the University of British Columbia, Vancouver. "There was some initial excitement using fractional photothermolysis, but I don't think that has panned out over time."

Lasers are not ideal for an epidermal nevus either, Dr. Lui said, due to a higher recurrence rate. However, he added, "in a highly motivated patient, I might do a test spot first."

A high recurrence rate and an unpredictable response are reasons to avoid laser treatment for café au lait macules, Dr. Lui said. Smaller lesions tend to respond the best. He advised caution, because there can be some paradoxical darkening in these patients.

Mixed Epidermal-Dermal Dyspigmentation. Expect a variable response to lasers for melanocytic nevi. "The best response is with small, junctional nevi." Use the highest fluence possible, Dr. Lui advised. An unknown long-term risk and incomplete pigment removal that can lead to problematic lesions are considerations. "Tell the patient that if the pigment does not completely clear, we are going to cut it out. You don't want to leave them with a lesion that meets one of the ABCD criteria [that could develop into melanoma someday]," Dr. Lui said.

Congenital melanocytic nevi may respond to a normal-mode ruby laser, but again, the long-term risk is unknown.

Dr. Lui generally does not recommend lasers for melasma. "The bottom line is that melasma will reliably darken with lasers. You can bet on it." Initial excitement about fractional lasers did not pan out, he added.

Dr. Lui also cautioned against lasers for postinflammatory hyperpigmentation. "A laser usually generates more postinflammatory hyperpigmentation. It's just a vicious circle, so the bottom line is 'Don't go there.' " Instead, convince your patient to be patient. "The best treatment is often time, and it's the cheapest, too."

Dermal Dyspigmentation. Nevus of Ota and nevus of Ito, which are more common in Asian patients, feature an excellent responsiveness to laser treatment, Dr. Lui said. "These are life-transforming types of procedures you can do for patients. This is why I became a doctor."

Lasers also are appropriate for treatment of Hori's macules. These often look like lentigines, Dr. Lui said. To distinguish between the two types of lesions, look for a blue-gray color (as opposed to a brown color with lentigines) and lesions that appear smudgy rather than well delineated.

Lasers can be used to treat blue nevi, but caution is advised, Dr. Lui said.

Dr. Lui said that he had no relevant financial disclosures.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.

ORLANDO - Foam sclerotherapy can be an effective treatment for varicose veins ranging from 1 mm to more than 5 mm in diameter, said Dr. Hema Sundaram, medical director of Sundaram Dermatology, Cosmetic & Laser Surgery in Rockville, Md.

As many as 20% of adults in the United States and Western Europe have varicose veins, and many of them can be successfully treated in a dermatology practice. Her treatment of choice for sclerotherapy is polidocanol, which was approved by the Food and Drug Administration last year for treating varicose veins. Polidocanol has been studied more extensively than any other sclerosant, noted Dr. Sundaram, who is in private practice in Rockville. The adverse events are low, allergic reactions are rare, and patients report less pain compared with other sclerosants.

She said that she successfully uses polidocanol for foam sclerotherapy. The best candidates for this off-label use are patients who have veins with varicosities from 1 mm to greater than 5 mm in diameter. For telangiectatic veins up to 1 mm in diameter, she prefers liquid polidocanol. "The foam can be a bit traumatic for the smaller veins," she said.

To treat varicose veins with foam, mix air with the sclerosant in a sclerosant:air ratio of 1:3 or 1:4, said Dr. Sundaram. She uses a three-way stopcock and a double syringe to combine the air and sclerosant. The foam in the syringe should resemble shaving foam.

Maintain a maximum foam volume of 10 mL per leg per session to minimize the risk of deep vein thrombosis, she noted.

"The important thing is to use the foam quickly, because the air will dissipate," Dr. Sundaram said. Stop injecting the foam when the flow of sclerosant into superficial veins is no longer visible.

For the right-sized veins, foam sclerotherapy can displace the blood more efficiently and put more of the sclerosant in contact with the vascular endothelial wall, Dr. Sundaram said.

Foam sclerotherapy has demonstrated safety and efficacy. In a review of data from 325 patients who were treated at a single center over 7 years, patients rated improvement as 1.94 on a scale of 3, while rating pain at 0.22, ulceration at 0.06, and hyperpigmentation at 0.35 (Dermatol. Surg. 2010;36[suppl. 2]:1026-33).

Dr. Sundaram’s foam sclerotherapy procedure is as follows:

• Inject while the patient is lying down.

• Start proximally and move distally; some smaller veins can be filled through larger ones.

• Start with the largest veins and work down.

• After injecting the sclerosant and removing the needle, compress the entire vein.

• Direct the patient to used graduated leg compression with bandages or stockings for 3 days to 3 weeks after the procedure.

Because foam sclerotherapy is an off-label use, be sure to include this fact in the informed consent form that patients sign, Dr. Sundaram noted.

Pretreatment evaluation is as important for a sclerotherapy patient as it is for a patient undergoing any other type of aesthetic procedure. "The assessment determines how successful we are going to be," she said.

She recommended an ultrasound evaluation prior to sclerotherapy in order to locate the reflux areas and to identify any insufficiency in the greater saphenous vein. Patients with greater saphenous vein insufficiency tend not to respond well to sclerotherapy and are more likely to experience recurrence of varicosities, she explained. In addition, these patients are at increased risk of superficial thrombophlebitis. Dr. Sundaram refers these patients to a vascular surgeon for evaluation and treatment.

Contraindications for sclerotherapy include allergy to the sclerosing agent, acute deep vein thrombosis, infection, and significant leg swelling, as well as pregnancy, polyneuropathy, severe asthma, and hypercoagulability.

Dr. Sundaram serves as an advisor, consultant, and/or clinical investigator for the following companies: Johnson & Johnson, Merz Aesthetics, Biopelle, Colorescience, Medicis, Merz, SkinMedica, Suneva Medical, Syneron/Candela, and Ulthera.