Aesthetic Dermatology

Cold atmospheric temperatures lead to lower humidity. In such conditions, water is more likely to evaporate from the skin, particularly in individuals with an impaired skin barrier. With the arrival of winter, a discussion of the importance of the skin barrier and how to repair it is appropriate. Notably, cosmeceutical barrier repair products have an important role to play.

The Skin Barrier

Several important functions are served by the skin barrier: preventing transepidermal water loss (TEWL), shielding the skin from allergens and irritants, and protecting against infections. This defensive role depends largely on corneocyte function and the surrounding extracellular matrix (J. Invest. Dermatol. 2005;125:183-200).

The cornified cell envelope that encases the corneocyte is a 10-nm-wide, insoluble layer composed of various highly crossed proteins, particularly loricrin, the principal component, and involucrin, desmoplakin, and periplakin (J. Cell Sci. 2001;114:3069-70). The envelope structure is formed via cross-linking by the calcium (Ca2+)-dependent transglutaminase-1 (TG-1) enzyme.

The water barrier function of the skin is largely attributed to the lipids in the extracellular matrix that surrounds the corneocytes (Adv. Lipid Res. 1991;24:1-26). (Of note, TEWL is considered insensible water loss through the skin, which differs from active perspiration.) This lipid mixture is composed of approximately 50% ceramides, 25% cholesterol, and 15% fatty acids (J. Lipid Res. 2007;48:2531-46). Changes in any of these three components of the extracellular matrix can lead to a disruption in skin barrier function.

Ceramides

Ceramides constitute 40% of the lipids in the human stratum corneum (SC) (J. Invest. Dermatol. 1987;88:2S-6S), but they are not present in significant amounts in the stratum granulosum or basal layer. Consequently, terminal differentiation is likely an important factor in ceramide synthesis. The basic structure of ceramides consists of a fatty acid covalently bound to a sphingoid base.

In a study conducted by Unilever, ceramide levels were shown to increase in keratinocytes after the exogenous application of sphingoid precursors (specifically tetra-acetyl phytosphingosine or TAPS) (J. Invest. Dermatol. 1996;106:871). In another study by Unilever, TAPS, combined with the fatty acids 1% linoleic acid and 1% juniperic acid, also increased ceramide levels (J. Invest. Dermatol. 1996;106:918). In the latter study, researchers found that barrier integrity was improved in patients treated with TAPS, and the improvement was even greater when TAPS was combined with linoleic and juniperic acids. These findings imply that topically applied lipid precursors integrate into ceramide biosynthetic pathways in the epidermis, augmenting SC ceramide levels and thus ameliorating barrier integrity.

Cholesterol

Most cholesterol is synthesized from acetate in cells such as the keratinocytes, although basal cells can also absorb cholesterol from the circulation. Cholesterol production increases when the epidermal barrier is impaired (“Skin Barrier.” New York: Taylor and Francis, 2006, pp. 33–42).

Both peroxisome proliferator-activated receptors and retinoid X receptors play a role in transporting cholesterol across keratinocyte cell membranes by augmenting expression of ABCA1, a membrane transporter that regulates cholesterol flow (“Fitzpatrick's Dermatology in General Medicine,” 7th ed., New York: McGraw-Hill, 2007, pp. 386-7).

Fatty Acids

Free fatty acids and fatty acids in the skin are bound in triglycerides, glycosylceramides, ceramides, and phospholipids. The free fatty acids in the SC are mainly straight chained (“Skin Barrier.” New York, Taylor and Francis, 2006, pp. 33–42). Essential fatty acids such as linoleic acid can be obtained only through the diet or topical application.

Currently, it is thought that no single lipid alone mediates barrier function, and that normal levels of ceramides, cholesterol, and fatty acids, in the correct ratio, are crucial for maintaining barrier integrity.

Interestingly, Man et al. evaluated barrier recovery by altering the barrier with acetone, then applying ceramides or fatty acids alone, or a combination of ceramides and fatty acids, and found that normal barrier recovery was achieved only with the application of all three extracellular matrix components—ceramides, fatty acids, and cholesterol (Arch. Dermatol. 1993;129:728-38).

Skin Barrier Repair

Occlusives. Occlusive ingredients, which are oily compounds often used in cosmetics because of their capacity to dissolve fats, coat the SC and inhibit TEWL. Occlusives also impart an emollient effect.

Petrolatum and mineral oil are two of the best occlusive ingredients available. Used as a skin care product since 1872 and considered one of the optimal moisturizing agents, petrolatum displays a water vapor loss resistance 170 times that of olive oil and is well known for being noncomedogenic (Dermatologica 1971;142:89-92; J. Am. Acad. Dermatol. 1989;20:272-7). By virtue of its long-standing status as the most effective occlusive moisturizing agent, petrolatum is typically thought of as the accepted standard to which other occlusive ingredients are measured (“Dry Skin and Moisturizers,” Boca Raton, Fla.:CRC Press, 2000, p. 251).

Other frequently used occlusive ingredients include beeswax, dimethicone, grapeseed oil, lanolin, paraffin, propylene glycol, soybean oil, and squalene (“Atlas of Cosmetic Dermatology,” New York: Churchill Livingstone, 2000, p. 83).

Significantly, occlusives are effective only when they coat the skin; upon removal, TEWL returns to its previous level. Occlusives are typically combined with humectant ingredients in moisturizers.

In 2004, investigators performing a randomized, double-blind, controlled trial observed that mineral oil and extra-virgin coconut oil were as efficacious and safe as moisturizers in treating mild to moderate xerosis in 34 patients, with both groups demonstrating enhanced surface lipid levels and skin hydration (Dermatitis 2004;15:109-16).

Natural oils. Given the increasing popularity of natural and organic ingredients, essential oils of botanic origin are now frequently used in moisturizing products or as moisturizing agents themselves. Some of the more effective include sunflower seed oil, evening primrose oil, olive oil, and jojoba oil.

Natural oils contain fatty acids that play key roles in maintaining the skin barrier. Linoleic acid, an omega-6 fatty acid, is present in sunflower, safflower, evening primrose, and jojoba oils. Besides its role as a component of structural lipids necessary for barrier integrity, linoleic acid is used by the body to produce γ-linolenic acid, a polyunsaturated essential cis-fatty acid important in prostaglandin synthesis and, thus, the inflammatory process.

Humectants. These water-soluble substances with high water absorption capacity can attract water from the atmosphere (if atmospheric humidity exceeds 80%) and from the underlying epidermis.

Application of a humectant results in a slight swelling of the stratum corneum, yielding the perception of smoother skin with fewer wrinkles. In low-humidity conditions, humectants may actually take water from the deeper epidermis and dermis, resulting in increased skin dryness (J. Biol. Chem. 2002;277:46,616-21), so these ingredients work better when combined with occlusive ingredients.

The most frequently used humectants include glycerin, sorbitol, sodium hyaluronate, urea, propylene glycol, α-hydroxy acids, and sugars, with glycerin especially important because it displays both humectant and occlusive qualities.

Glycerin. Glycerin (glycerol) exhibits hygroscopic characteristics closely resembling those of natural moisturizing factor (J. Soc. Cosmet. Chem. 1976;27:65). This allows the stratum corneum to retain high water content even in an arid environment.

Recently, glycerol was shown to play an important role in skin hydration, insofar as glycerol levels were shown to be associated with stratum corneum hydration levels (J. Invest. Dermatol. 2005;125:288-93).

Previously, two high-glycerin moisturizers were compared with 16 other popular moisturizers in 394 patients with severely dry skin (“Dry Skin and Moisturizers,” Baton Roca, Fla.:CRC Press, 2000, p. 217). The high-glycerin products were found to be superior to all the other products tested because they rapidly restored dry skin to normal hydration levels and helped prevent a return to dryness for a longer period than the other formulations, even those containing petrolatum. Of note, glycerin is included in the new Vaseline Intensive Rescue Moisture Locking Lotion and Dove lotion.

Climatic and Endogenous Changes

Cold, low humidity, aging-related changes in hormone levels, and even cholesterol-lowering statin drugs can contribute significantly to dry skin. Therefore, products used last year or even last month might not be ideal today.

When patients plan to travel from a warm-weather climate to colder areas during the winter, I remind them that the skin needs 3 days to acclimate and marshal its defensive capacity against cold temperatures. I also suggest that they moisturize on airplanes, where air is very dry, and plan to moisturize more frequently in cold-weather environments.

Specifically, I recommend what I consider to be the best barrier repair moisturizers: the Dove Proage product line, AtoPalm MLE Face Cream, MoistureWorx by DermWorx Inc., and Kinerase Ultra Rich Night Repair cream. For the body, I recommend TriCeram Ceramide Dominant Barrier Repair, Dove Proage Beauty Body Lotion, Vaseline Intensive Rescue Moisture Locking Lotion, Cetaphil Moisturizing Cream, and CeraVe Moisturizing Cream.

Regardless of the climatic conditions, for patients with dry skin, I always caution against using foaming cleansers, bubble baths, and bar soap, which denude the epidermis of lipids. Rather, I suggest a cleansing oil such as Shu Uemura or Laura Mercier cleansing oils. CeraVe, Dove, Aveeno, and Cetaphil are appropriate cleansers for moderately dry skin, and cold creams, such as Ponds and Noxema, are well suited for very dry skin. For nonfacial dry and sensitive skin not prone to body acne, a suitable product is Grandma Minnie's Oil's Well Nurturing Do-It-Oil (patients with a tendency to get acne should be advised to avoid this product or any other than contains coconut oil).

Finally, I remind patients that the skin and skin barrier can be repaired through diet and dietary supplementation. Specifically, omega-3 fatty acids, borage seed oil, and evening primrose oil may strengthen the skin barrier and ameliorate dryness and itching.

Cold atmospheric temperatures lead to lower humidity. In such conditions, water is more likely to evaporate from the skin, particularly in individuals with an impaired skin barrier. With the arrival of winter, a discussion of the importance of the skin barrier and how to repair it is appropriate. Notably, cosmeceutical barrier repair products have an important role to play.

The Skin Barrier

Several important functions are served by the skin barrier: preventing transepidermal water loss (TEWL), shielding the skin from allergens and irritants, and protecting against infections. This defensive role depends largely on corneocyte function and the surrounding extracellular matrix (J. Invest. Dermatol. 2005;125:183-200).

The cornified cell envelope that encases the corneocyte is a 10-nm-wide, insoluble layer composed of various highly crossed proteins, particularly loricrin, the principal component, and involucrin, desmoplakin, and periplakin (J. Cell Sci. 2001;114:3069-70). The envelope structure is formed via cross-linking by the calcium (Ca2+)-dependent transglutaminase-1 (TG-1) enzyme.

The water barrier function of the skin is largely attributed to the lipids in the extracellular matrix that surrounds the corneocytes (Adv. Lipid Res. 1991;24:1-26). (Of note, TEWL is considered insensible water loss through the skin, which differs from active perspiration.) This lipid mixture is composed of approximately 50% ceramides, 25% cholesterol, and 15% fatty acids (J. Lipid Res. 2007;48:2531-46). Changes in any of these three components of the extracellular matrix can lead to a disruption in skin barrier function.

Ceramides

Ceramides constitute 40% of the lipids in the human stratum corneum (SC) (J. Invest. Dermatol. 1987;88:2S-6S), but they are not present in significant amounts in the stratum granulosum or basal layer. Consequently, terminal differentiation is likely an important factor in ceramide synthesis. The basic structure of ceramides consists of a fatty acid covalently bound to a sphingoid base.

In a study conducted by Unilever, ceramide levels were shown to increase in keratinocytes after the exogenous application of sphingoid precursors (specifically tetra-acetyl phytosphingosine or TAPS) (J. Invest. Dermatol. 1996;106:871). In another study by Unilever, TAPS, combined with the fatty acids 1% linoleic acid and 1% juniperic acid, also increased ceramide levels (J. Invest. Dermatol. 1996;106:918). In the latter study, researchers found that barrier integrity was improved in patients treated with TAPS, and the improvement was even greater when TAPS was combined with linoleic and juniperic acids. These findings imply that topically applied lipid precursors integrate into ceramide biosynthetic pathways in the epidermis, augmenting SC ceramide levels and thus ameliorating barrier integrity.

Cholesterol

Most cholesterol is synthesized from acetate in cells such as the keratinocytes, although basal cells can also absorb cholesterol from the circulation. Cholesterol production increases when the epidermal barrier is impaired (“Skin Barrier.” New York: Taylor and Francis, 2006, pp. 33–42).

Both peroxisome proliferator-activated receptors and retinoid X receptors play a role in transporting cholesterol across keratinocyte cell membranes by augmenting expression of ABCA1, a membrane transporter that regulates cholesterol flow (“Fitzpatrick's Dermatology in General Medicine,” 7th ed., New York: McGraw-Hill, 2007, pp. 386-7).

Fatty Acids

Free fatty acids and fatty acids in the skin are bound in triglycerides, glycosylceramides, ceramides, and phospholipids. The free fatty acids in the SC are mainly straight chained (“Skin Barrier.” New York, Taylor and Francis, 2006, pp. 33–42). Essential fatty acids such as linoleic acid can be obtained only through the diet or topical application.

Currently, it is thought that no single lipid alone mediates barrier function, and that normal levels of ceramides, cholesterol, and fatty acids, in the correct ratio, are crucial for maintaining barrier integrity.

Interestingly, Man et al. evaluated barrier recovery by altering the barrier with acetone, then applying ceramides or fatty acids alone, or a combination of ceramides and fatty acids, and found that normal barrier recovery was achieved only with the application of all three extracellular matrix components—ceramides, fatty acids, and cholesterol (Arch. Dermatol. 1993;129:728-38).

Skin Barrier Repair

Occlusives. Occlusive ingredients, which are oily compounds often used in cosmetics because of their capacity to dissolve fats, coat the SC and inhibit TEWL. Occlusives also impart an emollient effect.

Petrolatum and mineral oil are two of the best occlusive ingredients available. Used as a skin care product since 1872 and considered one of the optimal moisturizing agents, petrolatum displays a water vapor loss resistance 170 times that of olive oil and is well known for being noncomedogenic (Dermatologica 1971;142:89-92; J. Am. Acad. Dermatol. 1989;20:272-7). By virtue of its long-standing status as the most effective occlusive moisturizing agent, petrolatum is typically thought of as the accepted standard to which other occlusive ingredients are measured (“Dry Skin and Moisturizers,” Boca Raton, Fla.:CRC Press, 2000, p. 251).

Other frequently used occlusive ingredients include beeswax, dimethicone, grapeseed oil, lanolin, paraffin, propylene glycol, soybean oil, and squalene (“Atlas of Cosmetic Dermatology,” New York: Churchill Livingstone, 2000, p. 83).

Significantly, occlusives are effective only when they coat the skin; upon removal, TEWL returns to its previous level. Occlusives are typically combined with humectant ingredients in moisturizers.

In 2004, investigators performing a randomized, double-blind, controlled trial observed that mineral oil and extra-virgin coconut oil were as efficacious and safe as moisturizers in treating mild to moderate xerosis in 34 patients, with both groups demonstrating enhanced surface lipid levels and skin hydration (Dermatitis 2004;15:109-16).

Natural oils. Given the increasing popularity of natural and organic ingredients, essential oils of botanic origin are now frequently used in moisturizing products or as moisturizing agents themselves. Some of the more effective include sunflower seed oil, evening primrose oil, olive oil, and jojoba oil.

Natural oils contain fatty acids that play key roles in maintaining the skin barrier. Linoleic acid, an omega-6 fatty acid, is present in sunflower, safflower, evening primrose, and jojoba oils. Besides its role as a component of structural lipids necessary for barrier integrity, linoleic acid is used by the body to produce γ-linolenic acid, a polyunsaturated essential cis-fatty acid important in prostaglandin synthesis and, thus, the inflammatory process.

Humectants. These water-soluble substances with high water absorption capacity can attract water from the atmosphere (if atmospheric humidity exceeds 80%) and from the underlying epidermis.

Application of a humectant results in a slight swelling of the stratum corneum, yielding the perception of smoother skin with fewer wrinkles. In low-humidity conditions, humectants may actually take water from the deeper epidermis and dermis, resulting in increased skin dryness (J. Biol. Chem. 2002;277:46,616-21), so these ingredients work better when combined with occlusive ingredients.

The most frequently used humectants include glycerin, sorbitol, sodium hyaluronate, urea, propylene glycol, α-hydroxy acids, and sugars, with glycerin especially important because it displays both humectant and occlusive qualities.

Glycerin. Glycerin (glycerol) exhibits hygroscopic characteristics closely resembling those of natural moisturizing factor (J. Soc. Cosmet. Chem. 1976;27:65). This allows the stratum corneum to retain high water content even in an arid environment.

Recently, glycerol was shown to play an important role in skin hydration, insofar as glycerol levels were shown to be associated with stratum corneum hydration levels (J. Invest. Dermatol. 2005;125:288-93).

Previously, two high-glycerin moisturizers were compared with 16 other popular moisturizers in 394 patients with severely dry skin (“Dry Skin and Moisturizers,” Baton Roca, Fla.:CRC Press, 2000, p. 217). The high-glycerin products were found to be superior to all the other products tested because they rapidly restored dry skin to normal hydration levels and helped prevent a return to dryness for a longer period than the other formulations, even those containing petrolatum. Of note, glycerin is included in the new Vaseline Intensive Rescue Moisture Locking Lotion and Dove lotion.

Climatic and Endogenous Changes

Cold, low humidity, aging-related changes in hormone levels, and even cholesterol-lowering statin drugs can contribute significantly to dry skin. Therefore, products used last year or even last month might not be ideal today.

When patients plan to travel from a warm-weather climate to colder areas during the winter, I remind them that the skin needs 3 days to acclimate and marshal its defensive capacity against cold temperatures. I also suggest that they moisturize on airplanes, where air is very dry, and plan to moisturize more frequently in cold-weather environments.

Specifically, I recommend what I consider to be the best barrier repair moisturizers: the Dove Proage product line, AtoPalm MLE Face Cream, MoistureWorx by DermWorx Inc., and Kinerase Ultra Rich Night Repair cream. For the body, I recommend TriCeram Ceramide Dominant Barrier Repair, Dove Proage Beauty Body Lotion, Vaseline Intensive Rescue Moisture Locking Lotion, Cetaphil Moisturizing Cream, and CeraVe Moisturizing Cream.

Regardless of the climatic conditions, for patients with dry skin, I always caution against using foaming cleansers, bubble baths, and bar soap, which denude the epidermis of lipids. Rather, I suggest a cleansing oil such as Shu Uemura or Laura Mercier cleansing oils. CeraVe, Dove, Aveeno, and Cetaphil are appropriate cleansers for moderately dry skin, and cold creams, such as Ponds and Noxema, are well suited for very dry skin. For nonfacial dry and sensitive skin not prone to body acne, a suitable product is Grandma Minnie's Oil's Well Nurturing Do-It-Oil (patients with a tendency to get acne should be advised to avoid this product or any other than contains coconut oil).

Finally, I remind patients that the skin and skin barrier can be repaired through diet and dietary supplementation. Specifically, omega-3 fatty acids, borage seed oil, and evening primrose oil may strengthen the skin barrier and ameliorate dryness and itching.

Cold atmospheric temperatures lead to lower humidity. In such conditions, water is more likely to evaporate from the skin, particularly in individuals with an impaired skin barrier. With the arrival of winter, a discussion of the importance of the skin barrier and how to repair it is appropriate. Notably, cosmeceutical barrier repair products have an important role to play.

The Skin Barrier

Several important functions are served by the skin barrier: preventing transepidermal water loss (TEWL), shielding the skin from allergens and irritants, and protecting against infections. This defensive role depends largely on corneocyte function and the surrounding extracellular matrix (J. Invest. Dermatol. 2005;125:183-200).

The cornified cell envelope that encases the corneocyte is a 10-nm-wide, insoluble layer composed of various highly crossed proteins, particularly loricrin, the principal component, and involucrin, desmoplakin, and periplakin (J. Cell Sci. 2001;114:3069-70). The envelope structure is formed via cross-linking by the calcium (Ca2+)-dependent transglutaminase-1 (TG-1) enzyme.

The water barrier function of the skin is largely attributed to the lipids in the extracellular matrix that surrounds the corneocytes (Adv. Lipid Res. 1991;24:1-26). (Of note, TEWL is considered insensible water loss through the skin, which differs from active perspiration.) This lipid mixture is composed of approximately 50% ceramides, 25% cholesterol, and 15% fatty acids (J. Lipid Res. 2007;48:2531-46). Changes in any of these three components of the extracellular matrix can lead to a disruption in skin barrier function.

Ceramides

Ceramides constitute 40% of the lipids in the human stratum corneum (SC) (J. Invest. Dermatol. 1987;88:2S-6S), but they are not present in significant amounts in the stratum granulosum or basal layer. Consequently, terminal differentiation is likely an important factor in ceramide synthesis. The basic structure of ceramides consists of a fatty acid covalently bound to a sphingoid base.

In a study conducted by Unilever, ceramide levels were shown to increase in keratinocytes after the exogenous application of sphingoid precursors (specifically tetra-acetyl phytosphingosine or TAPS) (J. Invest. Dermatol. 1996;106:871). In another study by Unilever, TAPS, combined with the fatty acids 1% linoleic acid and 1% juniperic acid, also increased ceramide levels (J. Invest. Dermatol. 1996;106:918). In the latter study, researchers found that barrier integrity was improved in patients treated with TAPS, and the improvement was even greater when TAPS was combined with linoleic and juniperic acids. These findings imply that topically applied lipid precursors integrate into ceramide biosynthetic pathways in the epidermis, augmenting SC ceramide levels and thus ameliorating barrier integrity.

Cholesterol

Most cholesterol is synthesized from acetate in cells such as the keratinocytes, although basal cells can also absorb cholesterol from the circulation. Cholesterol production increases when the epidermal barrier is impaired (“Skin Barrier.” New York: Taylor and Francis, 2006, pp. 33–42).

Both peroxisome proliferator-activated receptors and retinoid X receptors play a role in transporting cholesterol across keratinocyte cell membranes by augmenting expression of ABCA1, a membrane transporter that regulates cholesterol flow (“Fitzpatrick's Dermatology in General Medicine,” 7th ed., New York: McGraw-Hill, 2007, pp. 386-7).

Fatty Acids

Free fatty acids and fatty acids in the skin are bound in triglycerides, glycosylceramides, ceramides, and phospholipids. The free fatty acids in the SC are mainly straight chained (“Skin Barrier.” New York, Taylor and Francis, 2006, pp. 33–42). Essential fatty acids such as linoleic acid can be obtained only through the diet or topical application.

Currently, it is thought that no single lipid alone mediates barrier function, and that normal levels of ceramides, cholesterol, and fatty acids, in the correct ratio, are crucial for maintaining barrier integrity.

Interestingly, Man et al. evaluated barrier recovery by altering the barrier with acetone, then applying ceramides or fatty acids alone, or a combination of ceramides and fatty acids, and found that normal barrier recovery was achieved only with the application of all three extracellular matrix components—ceramides, fatty acids, and cholesterol (Arch. Dermatol. 1993;129:728-38).

Skin Barrier Repair

Occlusives. Occlusive ingredients, which are oily compounds often used in cosmetics because of their capacity to dissolve fats, coat the SC and inhibit TEWL. Occlusives also impart an emollient effect.

Petrolatum and mineral oil are two of the best occlusive ingredients available. Used as a skin care product since 1872 and considered one of the optimal moisturizing agents, petrolatum displays a water vapor loss resistance 170 times that of olive oil and is well known for being noncomedogenic (Dermatologica 1971;142:89-92; J. Am. Acad. Dermatol. 1989;20:272-7). By virtue of its long-standing status as the most effective occlusive moisturizing agent, petrolatum is typically thought of as the accepted standard to which other occlusive ingredients are measured (“Dry Skin and Moisturizers,” Boca Raton, Fla.:CRC Press, 2000, p. 251).

Other frequently used occlusive ingredients include beeswax, dimethicone, grapeseed oil, lanolin, paraffin, propylene glycol, soybean oil, and squalene (“Atlas of Cosmetic Dermatology,” New York: Churchill Livingstone, 2000, p. 83).

Significantly, occlusives are effective only when they coat the skin; upon removal, TEWL returns to its previous level. Occlusives are typically combined with humectant ingredients in moisturizers.

In 2004, investigators performing a randomized, double-blind, controlled trial observed that mineral oil and extra-virgin coconut oil were as efficacious and safe as moisturizers in treating mild to moderate xerosis in 34 patients, with both groups demonstrating enhanced surface lipid levels and skin hydration (Dermatitis 2004;15:109-16).

Natural oils. Given the increasing popularity of natural and organic ingredients, essential oils of botanic origin are now frequently used in moisturizing products or as moisturizing agents themselves. Some of the more effective include sunflower seed oil, evening primrose oil, olive oil, and jojoba oil.

Natural oils contain fatty acids that play key roles in maintaining the skin barrier. Linoleic acid, an omega-6 fatty acid, is present in sunflower, safflower, evening primrose, and jojoba oils. Besides its role as a component of structural lipids necessary for barrier integrity, linoleic acid is used by the body to produce γ-linolenic acid, a polyunsaturated essential cis-fatty acid important in prostaglandin synthesis and, thus, the inflammatory process.

Humectants. These water-soluble substances with high water absorption capacity can attract water from the atmosphere (if atmospheric humidity exceeds 80%) and from the underlying epidermis.

Application of a humectant results in a slight swelling of the stratum corneum, yielding the perception of smoother skin with fewer wrinkles. In low-humidity conditions, humectants may actually take water from the deeper epidermis and dermis, resulting in increased skin dryness (J. Biol. Chem. 2002;277:46,616-21), so these ingredients work better when combined with occlusive ingredients.

The most frequently used humectants include glycerin, sorbitol, sodium hyaluronate, urea, propylene glycol, α-hydroxy acids, and sugars, with glycerin especially important because it displays both humectant and occlusive qualities.

Glycerin. Glycerin (glycerol) exhibits hygroscopic characteristics closely resembling those of natural moisturizing factor (J. Soc. Cosmet. Chem. 1976;27:65). This allows the stratum corneum to retain high water content even in an arid environment.

Recently, glycerol was shown to play an important role in skin hydration, insofar as glycerol levels were shown to be associated with stratum corneum hydration levels (J. Invest. Dermatol. 2005;125:288-93).

Previously, two high-glycerin moisturizers were compared with 16 other popular moisturizers in 394 patients with severely dry skin (“Dry Skin and Moisturizers,” Baton Roca, Fla.:CRC Press, 2000, p. 217). The high-glycerin products were found to be superior to all the other products tested because they rapidly restored dry skin to normal hydration levels and helped prevent a return to dryness for a longer period than the other formulations, even those containing petrolatum. Of note, glycerin is included in the new Vaseline Intensive Rescue Moisture Locking Lotion and Dove lotion.

Climatic and Endogenous Changes

Cold, low humidity, aging-related changes in hormone levels, and even cholesterol-lowering statin drugs can contribute significantly to dry skin. Therefore, products used last year or even last month might not be ideal today.

When patients plan to travel from a warm-weather climate to colder areas during the winter, I remind them that the skin needs 3 days to acclimate and marshal its defensive capacity against cold temperatures. I also suggest that they moisturize on airplanes, where air is very dry, and plan to moisturize more frequently in cold-weather environments.

Specifically, I recommend what I consider to be the best barrier repair moisturizers: the Dove Proage product line, AtoPalm MLE Face Cream, MoistureWorx by DermWorx Inc., and Kinerase Ultra Rich Night Repair cream. For the body, I recommend TriCeram Ceramide Dominant Barrier Repair, Dove Proage Beauty Body Lotion, Vaseline Intensive Rescue Moisture Locking Lotion, Cetaphil Moisturizing Cream, and CeraVe Moisturizing Cream.

Regardless of the climatic conditions, for patients with dry skin, I always caution against using foaming cleansers, bubble baths, and bar soap, which denude the epidermis of lipids. Rather, I suggest a cleansing oil such as Shu Uemura or Laura Mercier cleansing oils. CeraVe, Dove, Aveeno, and Cetaphil are appropriate cleansers for moderately dry skin, and cold creams, such as Ponds and Noxema, are well suited for very dry skin. For nonfacial dry and sensitive skin not prone to body acne, a suitable product is Grandma Minnie's Oil's Well Nurturing Do-It-Oil (patients with a tendency to get acne should be advised to avoid this product or any other than contains coconut oil).

Finally, I remind patients that the skin and skin barrier can be repaired through diet and dietary supplementation. Specifically, omega-3 fatty acids, borage seed oil, and evening primrose oil may strengthen the skin barrier and ameliorate dryness and itching.

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Certain widely held beliefs among dermatologic surgeons are revealed as myths when subjected to scientific scrutiny, according to Dr. James M. Spencer.

"In surgery we do a lot of things just because a respected professor once told us to," said Dr. Spencer of Mount Sinai School of Medicine, New York.

An example Dr. Spencer cited is the dictum that one should never use epinephrine with lidocaine on the fingers, because the epinephrine is so vasoconstrictive that hypoxia and necrosis would result. This prohibition is included as dogma in textbooks—yet a literature review identified only 50 reported cases of digital gangrene following local anesthesia. All of these were early 20th century cases and multiple medications were involved, including cocaine and procaine, with nonstandardized techniques and methods of mixing, he said.

These early cases also included the inappropriate use of tourniquets and postoperative hot soaks (J. Am. Acad. Dermatol. 2004;51:755–9). There have been no reports of necrosis of the finger since commercial lidocaine with epinephrine was introduced in 1948, Dr. Spencer said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Another myth is that dog-ears must be completely removed at the time of surgery or they will be permanent. "I was taught 'thou shalt not leave dog-ears,' but this is clearly untrue," he said.

"When I had my first job at the University of Miami, the chairman of the department of plastic surgery would do primary repairs leaving patients with dog-ears. I wondered why no one had ever told him not to leave dog-ears, but then I thought, what are the chances of me being right and the chairman of plastic surgery being wrong? Zero," he said.

When this was studied prospectively, in 43 postexcision dog-ears in 26 patients, some degree of regression was seen in all 43. The dog-ears were measured immediately postoperatively and followed for up to 180 days. Complete regression was seen in 19 of the 43, over a mean of 132 days, and the probability of complete regression was greater in dog-ears of 8 mm in height or less (Dermatol. Surg. 2008;34:1070–6).

"I can tell you from experience that dog-ears on hands regress completely, those on arms and legs do pretty well, but those on the forehead not at all," he said.

"We also were all taught that nonabsorbable sutures are always preferred as outer, cuticular sutures because absorbable sutures are too inflammatory, they favor infection, and give an inferior cosmetic result," he said.

Patients, however, would prefer not to have to return for suture removal, so a group of emergency physicians performed a study in which they randomized pediatric patients with lacerations to treatment with absorbable plain gut sutures or nonabsorbable nylon sutures and evaluated them at 10 days and at 4–5 months.

At 10-day follow-up, there were no differences in wound outcome, including infection and dehiscence rates, and 4–5 months later, evaluation by a blinded plastic surgeon showed no difference in cosmetic outcome (Acad. Emerg. Med. 2004;11:730–5). "In fact, the plain gut sutures appeared to give a slightly better cosmetic result," said Dr. Spencer, who also is in private practice in St. Petersburg, Fla.

Another myth that has been perpetuated by dermatologists is that patients receive 80% of their lifetime sun exposure by age 18.

The 80% number was an extrapolation from a calculation in 1986 that sunscreen use by young people would reduce their lifetime risk of skin cancer by 78%. In fact, the original publication stated that the incidence of nonmelanoma skin cancer was related to the square of the ultraviolet dose—the actual dose was not calculated (Arch. Derm. 1986;122:537–45).

A more recent analysis determined that Americans actually receive less than 25% of their total exposure by age 18 (Photochem. Photobiol. 2003;77:453–7). "This, of course, means that sun protection is equally important in older and younger patients," he said.

Finally, it has been accepted that laser resurfacing is contraindicated while a patient is on isotretinoin, but there is very little evidence to support this, with only nine cases of keloid scarring having been reported. Six were from Dr. Henry Roenigk in Chicago, who has done thousands of cases of dermabrasion on patients with acne scars who were on isotretinoin or had only recently discontinued it (J. Am. Acad. Dermatol. 1986;15:280–5). The remaining three were patients from Great Britain who developed scarring after dermabrasion or argon laser while taking isotretinoin (Br. J. Dermatol. 1988;118:703–6).

"That's it. Nine patients in the world literature have become a medicolegal fact. Textbooks don't even reference it, they just state it like it's the 11th commandment."

Dr. Spencer disclosed having no conflicts of interest relevant to his presenation.

'I was taught "thou shalt not leave dog-ears," but this is clearly untrue.' DR. SPENCER

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

PALM BEACH, FLA. — Purse-string closure is a useful technique for difficult postsurgical cases in patients who cannot tolerate long procedures or who have difficulty with follow-up, according to Dr. John Robert Hamill Jr.

This technique also minimizes scarring, especially in areas of high tension or thin skin, with the final scar almost always being significantly smaller than the original defect, Dr. Hamill said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Purse-string closure of defects after surgery for skin cancer—with sutures placed around the defect and the skin pulled together—is cost effective. "I charge for intermediate closure for this procedure, eliminating the need for flaps, grafts, and multiple staged procedures," said Dr. Hamill of the department of dermatology and cutaneous surgery at the University of South Florida, Tampa.

For example, this was suitable for an elderly nursing home patient with malignant melanoma in situ on the left lower arm (see images above).

"The patient had multiple medical problems, and both she and her daughter wanted almost no surgery, so I did the simplest thing I could," said Dr. Hamill, director of the advanced dermatology surgery clinic at James A. Haley Veterans' Hospital, Tampa, and medical director at Gulf Coast Dermatology, Hudson, Fla.

The original 2.8-by-2.9-cm defect was closed with nylon skin sutures at the concentric redundant skin folds, and the final 0.7-by-0.5-cm defect left to granulate. "The skin here is bunchy, but in this type of patient you can get away with that because the skin is so loose. The puffiness will go down," he said.

Two months later, there was a small amount of breakdown and granulation tissue in the center of the defect, which was debrided in standard fashion with curetting, electrocautery, and topical aluminum chloride. Once the crust was scraped off the dermis was perfect, Dr. Hamill said at the meeting.

Because of the patient's complex medical problems she was unable to return for further follow-up, but a phone call to the nursing home determined that she was "perfectly healed and perfectly happy," he said.

"This is the type of surgery I would want my own grandmother to have because of its simplicity and lack of complications," he said.

The main disadvantages of the purse-string closure are the marked distortion of the skin immediately following the surgery and the possibility that simple scar revision may be needed in areas of high tension. But with a careful preoperative discussion, and the patient's being shown photos of other patients' outcomes, these are generally not major problems.

"In general, my patients have been extremely happy with this technique," Dr. Hamill concluded.

The lower left arm of the elderly nursing home patient with malignant melanoma in situ is shown before excision (left); immediately following excision (middle); and 2 weeks after surgery (right). The patient was "perfectly healed" and happy. Photos courtesy Dr. John Robert Hamill Jr.

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

LAS VEGAS — The incidence of complications following skin surgery is no different in smokers, compared with nonsmokers, results from a 5-year, single-center study demonstrated.

The finding flies in the face of conventional thinking that smokers "do worse after skin surgery, that they heal slower, and that they get more infections," Dr. Anthony Dixon said at the annual meeting of the International Society for Dermatologic Surgery.

A study from 1992 suggested that smoking compromises wound repair in part because nicotine reduces blood flow to the skin and increases blood platelet aggregation, which raises the risk of microthrombosis (Am. J. Med. 1992;93:22S-4S). The author also said that carbon monoxide decreases oxygen transport and metabolism.

"But unfortunately, until now there hasn't been a long prospective trial to find out whether or not this theory is true," said Dr. Dixon of the dermatology department at Australia's Bond University in Robina, Queensland. "Many dermatologists advise patients to cease smoking for a week prior to having skin surgery. There's no evidence base for that."

He and his associates conducted an observational study of 7,224 lesions excised on 4,197 patients between July 2002 and July 2007. Dr. Dixon performed all procedures; the average patient age was 65 years, and 55% were male.

In all, there were 286 complications (3.96%). The most common complication was infection, followed by bleeding, dehiscence, and skin necrosis.

Dr. Dixon reported that the incidence of total complications was similar between smokers and nonsmokers (3.6% vs. 4.0%, respectively). The incidence of infection was 1.9% in smokers, compared with 2.2% in nonsmokers, a difference that was not statistically significant. Bleeding occurred in 0.2% of smokers and in 0.8% of nonsmokers, a difference that was also not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that smoking did not predict any complication.

Based on these findings, "we can't justify smoking cessation prior to skin surgery," said Dr. Dixon, who emphasized that he and his fellow researchers "are all nonsmokers and we encourage our patients not to smoke for other health reasons. There are certainly things we try to get our patients to remember prior to surgery, but stopping smoking is not one of them."

In an interview, he acknowledged certain limitations of the study, including the fact that some of the patients may have been smokers but did not declare themselves as such. "Also, Australia has one of the lowest rates of smoking in the Western world and this may not reflect circumstances in countries with much higher smoking rates," he said.

In a separate analysis to be published in Dermatologic Surgery, he and his associates studied the same patient population to investigate the incidence of complications after skin surgery in diabetic and nondiabetic patients. Of the 4,197 patients in the study, 196 had known diabetes and 4,001 did not. The average age of diabetic patients was 72 years.

The incidence of total complications between diabetic and nondiabetic patients was the same, at 1.8%, but the incidence of infection was significantly higher in patients with diabetes (4.2%), compared with those without (2.0%). Bleeding occurred in 0.9% of diabetic patients and 0.7% of nondiabetic patients, a difference that was not statistically significant.

Logistic regression analysis that adjusted for age, sex, operation type, lesion diagnosis, body site location, and socioeconomic background found that a known history of diabetes was predictive of infection.

Dr. Dixon, who is also director of research for a group of skin cancer clinics in Australia, had no disclosures to make.

Patients are advised to cease smoking 1 week before skin surgery. 'There's no evidence base for that.' DR. DIXON

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

Stretch marks, or striae distensae, are scar tissue in the skin's dermal layer that result from rapid growth or weight gain. These lesions, which can be found crisscrossing the breasts, abdomen, hips, thighs, buttocks, and arms, occur in females and males, particularly as a result of adolescent growth spurts, pregnancy, obesity, rapid muscle growth (from weight lifting, for example), and prolonged use of topical steroids.

In these instances or periods of growth, collagen and elastin are not produced fast enough to accommodate the expansion of other cutaneous layers, rendering the normally elastic dermis less flexible and manifesting in visible epidermal marks.

Initially, these dermal alterations present as pink, red, or purple lesions, known as striae rubra. If the lesions are untreated, they become white (striae alba) and the texture of the lesion may change from swollen to flattened or moderately depressed. A high proportion of teenage girls and pregnant women are beset with striae distensae.

Dermatologists now have a number of options to tackle this cosmetically stressful condition, including novel laser treatments for striae alba, but the primary focus here is on topical and cosmeceutical options.

Prevention

There is no surefire method to prevent stretch marks per se, but avoidance of a rapid gain or loss of weight improves one's chances of not developing these lesions.

Several topical agents have demonstrated efficacy in high-risk patients. For individuals who are pregnant or experiencing adolescent hormonal changes, moisturizing three or four times daily is recommended. Skin becomes more pliant and elastic when it is well hydrated. Moisturizers that contain cocoa butter, shea butter, or Centella asiatica (also known as gotu kola) as a prime ingredient are the best. To increase their efficacy, massage such formulations deeply into the affected areas. I recommend Belli Elasticity Belly Oil, which contains healthy amounts of both cocoa butter and C. asiatica, to my patients.

Treatment

Identifying striae distensae early is crucial. Patients should be advised to seek treatment when stretch marks are still red or purple because the lesions are most likely to respond to at-home products and in-office peels at this stage. Once stretch marks are white, treatment becomes more difficult and less successful.

Striae rubra may respond to the glycolic acid in various over-the-counter (OTC) lotions, most likely through the alpha-hydroxy acid's capacity to stimulate collagen synthesis. I recommend brands with the highest concentration of glycolic acid, such as MD Forté Glycare I and NeoStrata Ultra Smoothing Lotion.

Topical vitamin C, if formulated properly, also has the capacity to promote collagen synthesis. It can be used individually or in combination with glycolic acid. I recommend SkinCeuticals C E Ferulic and La Roche-Posay Active C. Supplementation with oral vitamin C 500 mg twice daily may also confer some benefit.

Relastin, marketed as an eye cream and a face cream, is touted by its manufacturer for its ability to increase elastic tissue, which may ameliorate stretch marks. Its efficacy is unconfirmed at this point.

Retinoids

In an early study of retinoids for the treatment of striae distensae, 16 of 20 patients with stretch marks from various causes completed the study, 15 of whom exhibited significant clinical improvement (J. Dermatol. Surg. Oncol. 1990;16:267–70).

Retinoids promote the production of collagen and elastin. When retinoids are massaged nightly into striae rubra, the appearance and texture of the lesions can improve significantly. In fact, the use of 0.1% tretinoin for the treatment of striae rubra has been established as effective for more than a decade (Dermatol. Surg. 1998;24:849–56). Retinoids are not as effective for the treatment of striae alba, however, and are contraindicated in pregnant and breastfeeding women.

In a study evaluating commercial topical products for the treatment of striae alba, investigators tested two regimens on 10 patients who had abdominal striae alba with skin types ranging from I to V. Patients applied 20% glycolic acid (MD Forté) to the whole treatment area on a daily basis for 12 weeks. Patients also were directed to apply 0.05% tretinoin emollient cream (Renova) to half of the treatment area, and 10% L-ascorbic acid, 2% zinc sulfate, and 0.5% tyrosine cream to the other half.

Improvement in the appearance of stretch marks, assessed at 4 and 12 weeks, was documented for both regimens. In addition, a comparison of treated striae alba with untreated lesions revealed that both regimens were effective in decreasing papillary dermal thickness and increasing epidermal thickness (Dermatol. Surg. 1998;24:849–56).

In another study evaluating the effects of a retinoid, 20 women applied tretinoin cream 0.1% to abdominal striae induced by pregnancy. In this open-label, multicenter, prospective study, researchers observed marked improvement in all striae after 3 months, compared with baseline, with an average 20% reduction in the length of the target lesion. Despite the emergence in 11 patients of erythema and scaling, topically applied tretinoin significantly ameliorated pregnancy-induced striae distensae (Adv. Ther. 2001;18:181–6).

I recommend OTC retinol products such as Philosophy Help Me and Neutrogena Healthy Skin to my patients. Of course, prescription retinoids such as Retin-A, Tazorac, and Differin are stronger and, therefore, may be more effective than retinol. I also suggest retinoic acid peels, such as the Ultra Peel Exfoliating Treatment or the Esthetique Peel.

In-Office Treatment

Glycolic acid can be administered in the office at higher doses than those contained in OTC products. After three or four visits, patients usually notice a slight change in the length, width, and intensity of striae rubra. In-office glycolic peels are safe for all skin types, although lower concentrations should be used for people with darker skin tones. As suggested above, the combination of glycolic acid and a retinoid can be effective. In fact, various prescription-strength retinoids are often applied as a preparation for a glycolic acid peel.

Lasers

Since vascular lasers are designed to treat dilated blood vessels, which are characteristic of striae rubra, they present a potent treatment option. These instruments are associated with epidermal turnover as well as increased collagen production and elastic remodeling. I prefer the Dornier 940-nm laser for stretch marks, but some physicians use the 585-nm or 595-nm laser.

In a recent study, investigators treated 20 patients with striae rubra using the 1,064-nm long-pulsed Nd:YAG laser, which has been successfully used to foster dermal collagen synthesis. Subjective evaluations were made by patients (with 55% rating the results as excellent), and the investigators used before-and-after photos to assess treatment efficacy. Forty percent of the doctors considered the results to be excellent. Overall, the investigators found this laser to be an effective option for treating striae rubra, with minimal side effects (Dermatol. Surg. 2008;34:686–91).

In another study, researchers evaluated the efficacy of the Therma Cool TC (Thermage Inc.), in combination with a 585-nm pulsed dye laser, for the treatment of striae distensae in people with darker skin types. Overall improvement was termed “good and very good” by 89% of the participants in the subjective evaluation. Skin biopsies of nine patients also revealed that the level of collagen fibers in each sample increased (Dermatol. Surg. 2007;33:29–34).

In a previous study of patients with dark skin types (IV-VI), researchers studied the effects of a nonablative 1,450-nm diode laser on striae distensae. Eleven Asian patients were treated with the laser with cryogen cooling spray on half of the body; the untreated half served as the control. The investigators concluded that, for patients with skin types IV-VI, the nonablative 1,450-nm diode laser is not a viable option for treating stretch marks (Lasers Surg. Med. 2006;38:196–9).

Intense Pulsed Light

In research on the efficacy of intense pulsed light (IPL), investigators treated 15 women with abdominal striae distensae. Their study was based on the reported efficacy of IPL in fostering the synthesis of collagen and the ordering of elastic fibers. Before-and-after photos and skin biopsies of all 15 patients exhibited significant clinical and microscopic improvements, including differences in dermal thickness (Dermatol. Surg. 2002;28:1124–30).

A more recent examination of an IPL infrared device, the NovaPlus, which attains high fluences with high-frequency stacked pulses, was conducted on 10 patients who had striae distensae. Review of before-and-after photographs and three-dimensional skin surface analysis yielded an equal outcome, and few subjects observed improvement, but histologic assessment revealed improvement in epidermal and dermal condition. The researchers concluded that additional treatment sessions might afford better chances for desired cosmetic results, given the absence of side effects (Aesthetic Plast. Surg. 2008;32:523–30).

Fractional Photothermolysis

Despite the enhancements in overall treatment of striae distensae, few modalities have provided promise in significantly improving the appearance of striae alba.

Perhaps until now. In a recent study of the safety and efficacy of fractional photothermolysis for the treatment of stretch marks in Asian skin, researchers irradiated the striae distensae on the right buttocks of six female volunteers aged 20–35 years using a 1,550-nm fractional photothermolysis laser.

Patients were followed for 2 months. Fleeting mild pain and hyperpigmentation were the adverse events reported. Overall, significant amelioration in the appearance of the stretch marks was observed 2 months after treatment. Histologic examination revealed a substantial increase in epidermal thickness as well as collagen and elastic fiber deposition. Investigators also noted that skin elasticity had become somewhat normalized (Am. J. Clin. Dermatol. 2008;9:33–7).

Conclusions

Although preventive measures can be used to reduce the likelihood of developing stretch marks, prevention is a challenge.

Treatment options are continually expanding. Glycolic acid and retinoids have demonstrated efficacy in in-office procedures and OTC products. Vitamin C may also impart some benefit. In addition, lasers are emerging as viable treatment options. The vascular laser is recommended for striae rubra and the Fraxel laser for striae alba.

Patients are advised to begin at-home treatment for stretch marks upon first noticing them and to schedule a dermatologic visit.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.

LAS VEGAS — The way Dr. Eliot F. Battle Jr. sees it, dermatologists should learn how to treat skin of color with cosmetic laser therapy for two reasons: to increase their revenue base as the world's population of brown-skinned individuals expands, and to improve their proficiency with operating lasers.

"You will never become an expert with lasers if you can't treat brown skin," Dr. Battle said at the annual meeting of the International Society for Dermatologic Surgery. "You have to embrace skin types IV-VI, for through this expertise we improved our ability to treat noninvasively and to treat tanned skin."

His Washington, D.C.-based practice is 37% African American, 27% white, 12% Hispanic, 8% Asian Pacific, 6% Asian, and 10% "other." Three of the top four nonsurgical procedures are laser hair removal, laser complexion blending—which he described as "evening out skin tone"—and laser skin tightening. (Botulinum toxin type A rounds out the top four.)

"We are going through an exciting time to treat skin of color, for we have more ammunition than ever to safely and effectively treat people of color in all areas of skin care, including cosmeceuticals, prescription medicines, aesthetic spa treatments, cosmetic laser treatments, and plastic surgery procedures," said Dr. Battle, a cosmetic dermatologist and laser surgeon.

In light-skinned individuals, melano-somes are small, and are packaged together in membranes. They remain around the basal layer of the epidermis.

In skin of color, melanosomes are more numerous, and are individually dispersed throughout all layers of the epidermis. Skin type VI patients can have melanin even in the stratum corneum. Some dermatologists "don't understand the genetic influence on melanin" Dr. Battle said, and deem darker ethnic skin as more difficult to treat with laser therapy.

Treating skin of color requires mastery of wavelengths, fluence, pulse duration, and cooling, said Dr. Battle, who is also on the faculty of the department of dermatology at Howard University, Washington.

Laser hair removal is especially effective in skin of color because black, coarse hair is an optimal target for the laser beam. "In [whites], hair removal is vanity because conventional methods such as shaving, waxing, and plucking work," Dr. Battle said. "People of color get dark spots from all of those methods."

Thermal side effects after laser therapy occur in skin of color when the skin temperature exceeds 45° C, so Dr. Battle maximizes cooling by using cold gel, slow treatments, ice packs post treatment, and cold air flow. "Be afraid of erythema," he warned. "In [whites] erythema resolves, but people of color get hyperpigmentation and redness. If you are going to do test spots, wait 48 hours for results. You can get blisters up to the second and third day after treatment."

If side effects do occur, be compassionate and empathetic and employ meticulous wound care. "Always be available to the patient," he advised. "Provide them with your cell phone number."

Dr. Battle disclosed having no conflicts of interest relevant to his presentation.

A patient is shown before (above) and 2 years after (below)undergoing nine laser hair removal sessions.

Hair removal is very effective in darker skin because black, coarse hair is an optimal target for the laser beam. Photos courtesy Dr. Eliot F. Battle Jr.