Aesthetic Dermatology

WASHINGTON – Microneedling is one of the hottest new trends in aesthetic dermatology and is easy to incorporate into any practice, according to Washington dermatologist Dr. Tina Alster.

Microneedling involves using an updated microneedle device to create small wounds on a patient’s area of concern. Perioral wrinkles, large pores on the nose, certain scars, and stretch marks all respond well to the procedure, Dr. Alster said at the annual meeting of the American Academy of Dermatology.

“I’ve been blown away by the fact that microneedling works as well as it does,” Dr. Alster added, noting that it’s not hard to do, it’s not hard to heal from, and it offers good results.

In this video interview, Dr. Alster explains how to do this microneedling procedures and how to incorporate the device into practice.

dfulton@frontlinemedcom.com

On Twitter @denisefulton

WASHINGTON – Microneedling is one of the hottest new trends in aesthetic dermatology and is easy to incorporate into any practice, according to Washington dermatologist Dr. Tina Alster.

Microneedling involves using an updated microneedle device to create small wounds on a patient’s area of concern. Perioral wrinkles, large pores on the nose, certain scars, and stretch marks all respond well to the procedure, Dr. Alster said at the annual meeting of the American Academy of Dermatology.

“I’ve been blown away by the fact that microneedling works as well as it does,” Dr. Alster added, noting that it’s not hard to do, it’s not hard to heal from, and it offers good results.

In this video interview, Dr. Alster explains how to do this microneedling procedures and how to incorporate the device into practice.

dfulton@frontlinemedcom.com

On Twitter @denisefulton

WASHINGTON – Microneedling is one of the hottest new trends in aesthetic dermatology and is easy to incorporate into any practice, according to Washington dermatologist Dr. Tina Alster.

Microneedling involves using an updated microneedle device to create small wounds on a patient’s area of concern. Perioral wrinkles, large pores on the nose, certain scars, and stretch marks all respond well to the procedure, Dr. Alster said at the annual meeting of the American Academy of Dermatology.

“I’ve been blown away by the fact that microneedling works as well as it does,” Dr. Alster added, noting that it’s not hard to do, it’s not hard to heal from, and it offers good results.

In this video interview, Dr. Alster explains how to do this microneedling procedures and how to incorporate the device into practice.

dfulton@frontlinemedcom.com

On Twitter @denisefulton

WAIKOLOA, HAWAII – Of the plethora of cellulite treatment devices on the market, the Food and Drug Administration has deemed only two capable of providing long-term improvement in the appearance of cellulite on the buttocks and thighs, Dr. Michael S. Kaminer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

These two devices are Cellulaze, a 1440 nm Nd:YAG laser typically utilized in conjunction with liposuction and marketed by Cynosure, and Cellfina, a semiautomated system for precise dermal undermining beneath cellulite dimples and marketed by Merz. Both devices target the structural problem that causes cellulite: subdermal fibrous septae that are tethered to the dermis, pulling down on the skin with resultant fat herniation and creation of cellulite dimples. The devices have the same mechanism of benefit, which entails cutting and thereby releasing the fibrous septae, albeit through two different technologies. Cellulaze cuts the fibrous septae with a laser fiber, while Cellfina uses a rapidly moving, piston-driven 18-gauge blade.

The superior efficacy of these two devices settles a long-standing controversy regarding the cause of cellulite, according to Dr. Kaminer, a dermatologist at Yale University, New Haven, Conn., and SkinCare Physicians of Chestnut Hill, Mass. “I think we now know what causes cellulite ... that if you cut the fibrous septae, things will improve.”

“There are a ton of devices (for treating cellulite) out there, but if you look at the literature none of them except Cellulaze and Cellfina have been shown to work,” he said. “Arguably the other options have, at most, limited efficacy.”

He cited a recent systematic evidence-based literature review led by Stefanie Luebberding, Ph.D., of the Rosenpark Clinic in Darmstadt, Germany. She and her coinvestigators concluded that “no clear evidence of good efficacy could be identified in any of the evaluated cellulite treatments,” which included shock wave and other forms of mechanical stimulation, massage, topical agents designed to plump up the skin, high- and low-energy laser therapies, infrared light, and radiofrequency (Am J Clin Dermatol. 2015 Aug;16[4]:243-56).

In U.S. clinical trials of Cellulaze, 68% of subjects had significant improvement at 1 year based on photographic evaluation and 65% based on Vectra three-dimensional surface imaging. Good to excellent results were reported by 76% of patients and 69% of physicians. On the downside, the Cellulaze device costs more than $100,000, recovery time is long, and the use of liposuction is falling in the United States, Dr. Kaminer observed.

He was the lead investigator in the multicenter study of Cellfina, in which 96% of patients in the open-label trial said they were satisfied or very satisfied with their results at 2 years post procedure.

From a mean baseline score of 3.4 on a 0-5 Cellulite Severity Scale, the average improvement was 2.0 points at both 1- and 2-year follow-up as assessed by independent physicians examining standardized professional photographs. Of 55 study participants, 2 experienced mild, transient adverse events (Dermatol Surg. 2015 Mar;41[3]:336-47).

Based on that trial, a single treatment session provides improvement lasting up to 1 year in the appearance of cellulite. Similar findings were noted 2 years after the procedure, said Dr. Kaminer, and he and his coinvestigators are now preparing to submit to the FDA the 3-year follow-up data, which show “essentially the same” sustained improvement.

Before the Cellfina procedure begins, the target cellulite dimples are marked on the standing patient. Roughly 20-25 dimples can be treated per session. The patient then assumes a prone position. A vacuum device is placed over the target area to control the depth and area of treatment. Tumescent anesthesia is injected, and then the piston-driven 18-gauge blade is introduced. The vacuum suction precisely controls the cutting depth at either 6 or 10 mm.

Dr. Kaminer noted that, potentially, the cellulite treatment market is colossal. One study concluded that an estimated 85% of American women age 24-54 have cellulite, and 37% of them – nearly 24 million women – say they are interested in a minimally invasive procedure to get rid of it.

“The definition of cellulite depends on what women you ask. Based on what I hear, 100% of women believe that they have cellulite and a lot of them are interested in having their cellulite treated,” he remarked.

Dr. Kaminer reported serving as a consultant to Merz, the maker of Cellfina, and receiving research funding from Cabochon, the maker of a system for improving the appearance of cellulite.

The SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Of the plethora of cellulite treatment devices on the market, the Food and Drug Administration has deemed only two capable of providing long-term improvement in the appearance of cellulite on the buttocks and thighs, Dr. Michael S. Kaminer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

These two devices are Cellulaze, a 1440 nm Nd:YAG laser typically utilized in conjunction with liposuction and marketed by Cynosure, and Cellfina, a semiautomated system for precise dermal undermining beneath cellulite dimples and marketed by Merz. Both devices target the structural problem that causes cellulite: subdermal fibrous septae that are tethered to the dermis, pulling down on the skin with resultant fat herniation and creation of cellulite dimples. The devices have the same mechanism of benefit, which entails cutting and thereby releasing the fibrous septae, albeit through two different technologies. Cellulaze cuts the fibrous septae with a laser fiber, while Cellfina uses a rapidly moving, piston-driven 18-gauge blade.

The superior efficacy of these two devices settles a long-standing controversy regarding the cause of cellulite, according to Dr. Kaminer, a dermatologist at Yale University, New Haven, Conn., and SkinCare Physicians of Chestnut Hill, Mass. “I think we now know what causes cellulite ... that if you cut the fibrous septae, things will improve.”

“There are a ton of devices (for treating cellulite) out there, but if you look at the literature none of them except Cellulaze and Cellfina have been shown to work,” he said. “Arguably the other options have, at most, limited efficacy.”

He cited a recent systematic evidence-based literature review led by Stefanie Luebberding, Ph.D., of the Rosenpark Clinic in Darmstadt, Germany. She and her coinvestigators concluded that “no clear evidence of good efficacy could be identified in any of the evaluated cellulite treatments,” which included shock wave and other forms of mechanical stimulation, massage, topical agents designed to plump up the skin, high- and low-energy laser therapies, infrared light, and radiofrequency (Am J Clin Dermatol. 2015 Aug;16[4]:243-56).

In U.S. clinical trials of Cellulaze, 68% of subjects had significant improvement at 1 year based on photographic evaluation and 65% based on Vectra three-dimensional surface imaging. Good to excellent results were reported by 76% of patients and 69% of physicians. On the downside, the Cellulaze device costs more than $100,000, recovery time is long, and the use of liposuction is falling in the United States, Dr. Kaminer observed.

He was the lead investigator in the multicenter study of Cellfina, in which 96% of patients in the open-label trial said they were satisfied or very satisfied with their results at 2 years post procedure.

From a mean baseline score of 3.4 on a 0-5 Cellulite Severity Scale, the average improvement was 2.0 points at both 1- and 2-year follow-up as assessed by independent physicians examining standardized professional photographs. Of 55 study participants, 2 experienced mild, transient adverse events (Dermatol Surg. 2015 Mar;41[3]:336-47).

Based on that trial, a single treatment session provides improvement lasting up to 1 year in the appearance of cellulite. Similar findings were noted 2 years after the procedure, said Dr. Kaminer, and he and his coinvestigators are now preparing to submit to the FDA the 3-year follow-up data, which show “essentially the same” sustained improvement.

Before the Cellfina procedure begins, the target cellulite dimples are marked on the standing patient. Roughly 20-25 dimples can be treated per session. The patient then assumes a prone position. A vacuum device is placed over the target area to control the depth and area of treatment. Tumescent anesthesia is injected, and then the piston-driven 18-gauge blade is introduced. The vacuum suction precisely controls the cutting depth at either 6 or 10 mm.

Dr. Kaminer noted that, potentially, the cellulite treatment market is colossal. One study concluded that an estimated 85% of American women age 24-54 have cellulite, and 37% of them – nearly 24 million women – say they are interested in a minimally invasive procedure to get rid of it.

“The definition of cellulite depends on what women you ask. Based on what I hear, 100% of women believe that they have cellulite and a lot of them are interested in having their cellulite treated,” he remarked.

Dr. Kaminer reported serving as a consultant to Merz, the maker of Cellfina, and receiving research funding from Cabochon, the maker of a system for improving the appearance of cellulite.

The SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

WAIKOLOA, HAWAII – Of the plethora of cellulite treatment devices on the market, the Food and Drug Administration has deemed only two capable of providing long-term improvement in the appearance of cellulite on the buttocks and thighs, Dr. Michael S. Kaminer said at the Hawaii Dermatology Seminar provided by Global Academy for Medical Education/Skin Disease Education Foundation.

These two devices are Cellulaze, a 1440 nm Nd:YAG laser typically utilized in conjunction with liposuction and marketed by Cynosure, and Cellfina, a semiautomated system for precise dermal undermining beneath cellulite dimples and marketed by Merz. Both devices target the structural problem that causes cellulite: subdermal fibrous septae that are tethered to the dermis, pulling down on the skin with resultant fat herniation and creation of cellulite dimples. The devices have the same mechanism of benefit, which entails cutting and thereby releasing the fibrous septae, albeit through two different technologies. Cellulaze cuts the fibrous septae with a laser fiber, while Cellfina uses a rapidly moving, piston-driven 18-gauge blade.

The superior efficacy of these two devices settles a long-standing controversy regarding the cause of cellulite, according to Dr. Kaminer, a dermatologist at Yale University, New Haven, Conn., and SkinCare Physicians of Chestnut Hill, Mass. “I think we now know what causes cellulite ... that if you cut the fibrous septae, things will improve.”

“There are a ton of devices (for treating cellulite) out there, but if you look at the literature none of them except Cellulaze and Cellfina have been shown to work,” he said. “Arguably the other options have, at most, limited efficacy.”

He cited a recent systematic evidence-based literature review led by Stefanie Luebberding, Ph.D., of the Rosenpark Clinic in Darmstadt, Germany. She and her coinvestigators concluded that “no clear evidence of good efficacy could be identified in any of the evaluated cellulite treatments,” which included shock wave and other forms of mechanical stimulation, massage, topical agents designed to plump up the skin, high- and low-energy laser therapies, infrared light, and radiofrequency (Am J Clin Dermatol. 2015 Aug;16[4]:243-56).

In U.S. clinical trials of Cellulaze, 68% of subjects had significant improvement at 1 year based on photographic evaluation and 65% based on Vectra three-dimensional surface imaging. Good to excellent results were reported by 76% of patients and 69% of physicians. On the downside, the Cellulaze device costs more than $100,000, recovery time is long, and the use of liposuction is falling in the United States, Dr. Kaminer observed.

He was the lead investigator in the multicenter study of Cellfina, in which 96% of patients in the open-label trial said they were satisfied or very satisfied with their results at 2 years post procedure.

From a mean baseline score of 3.4 on a 0-5 Cellulite Severity Scale, the average improvement was 2.0 points at both 1- and 2-year follow-up as assessed by independent physicians examining standardized professional photographs. Of 55 study participants, 2 experienced mild, transient adverse events (Dermatol Surg. 2015 Mar;41[3]:336-47).

Based on that trial, a single treatment session provides improvement lasting up to 1 year in the appearance of cellulite. Similar findings were noted 2 years after the procedure, said Dr. Kaminer, and he and his coinvestigators are now preparing to submit to the FDA the 3-year follow-up data, which show “essentially the same” sustained improvement.

Before the Cellfina procedure begins, the target cellulite dimples are marked on the standing patient. Roughly 20-25 dimples can be treated per session. The patient then assumes a prone position. A vacuum device is placed over the target area to control the depth and area of treatment. Tumescent anesthesia is injected, and then the piston-driven 18-gauge blade is introduced. The vacuum suction precisely controls the cutting depth at either 6 or 10 mm.

Dr. Kaminer noted that, potentially, the cellulite treatment market is colossal. One study concluded that an estimated 85% of American women age 24-54 have cellulite, and 37% of them – nearly 24 million women – say they are interested in a minimally invasive procedure to get rid of it.

“The definition of cellulite depends on what women you ask. Based on what I hear, 100% of women believe that they have cellulite and a lot of them are interested in having their cellulite treated,” he remarked.

Dr. Kaminer reported serving as a consultant to Merz, the maker of Cellfina, and receiving research funding from Cabochon, the maker of a system for improving the appearance of cellulite.

The SDEF and this news organization are owned by the same parent company.

bjancin@frontlinemedcom.com

HOLLYWOOD, FL. – Less may be more when it comes to liquid silicone for lip enhancement.

Tiny droplets of silicone, placed judiciously and built up gradually, can give a soft, natural, permanent effect, according to Dr. Robert Shumway, president of the American Academy of Cosmetic Surgery.

“Liquid silicone is one of the most awesome fillers you can use, as long as you use it correctly,” said Dr. Shumway at the annual meeting of the American Academy of Cosmetic Surgery. He discussed silicone lip enhancement at the meeting jointly with Dr. Salvador Renteria, his colleague in private practice in La Jolla, Calif.

Using strategically placed microdroplets can produce “permanent, soft, and amazing” results with the correct technique, said Dr. Shumway. The only equipment needed is a 27 gauge needle and a 1 cc syringe, together with the purified liquid silicone material, technically termed polydimethylsiloxane. Silicone is also relatively cost effective for all involved, he said.

Free liquid silicone is only currently approved by the FDA for ophthalmic use, and it’s this formulation that is also used off-label for cosmetic procedures. The fact that cosmetic injection of liquid silicone is off label can present a marketing barrier, and physicians must be careful to adhere to state regulations regarding advertising off-label procedures.

For Dr. Renteria and Dr. Shumway, it also means that a special patient consent form must be used, and carefully reviewed with patients. “We go over this form with them about all the complications that can occur, that it is permanent, that it’s going to require more than one session,” said Dr. Renteria.

The injection technique involves beginning at the lateral commissures and proceeding toward the philtrum in an outline fashion with microdroplets, then adding some volume to the lips after the outline has been enhanced. “In particular, you can augment the philtrum, which gives anterior projection,” said Dr. Renteria. The total amount of liquid silicone injected per session is usually about 0.5 to 0.8 cc, he said.

Managing patient expectations is also important, said Dr. Renteria. “We have a fairly lengthy discussion about what their desires are,” he said.

The interval between injection sessions should be six to eight weeks, and multiple sessions may be required. This interval between treatment sessions allows fibroplasia to occur, so the tissue surrounding the silicone has a similar texture to the injected material. “You’re never going to try to achieve the goal in one session,” said Dr. Shumway.

“Each droplet’s going to grow, which is why you give it 6 to 8 weeks for that growth to occur and encapsulate around each droplet. That’s important, because you don’t get the final result for at least 2 months,” added Dr. Renteria.

Patient compliance with this schedule is essential: “You are the one who has to be in control” of the injection schedule, said Dr. Shumway. “If you’re patient, and your patient is patient, you can get excellent results.”

Dr. Shumway and Dr. Renteria reported no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

HOLLYWOOD, FL. – Less may be more when it comes to liquid silicone for lip enhancement.

Tiny droplets of silicone, placed judiciously and built up gradually, can give a soft, natural, permanent effect, according to Dr. Robert Shumway, president of the American Academy of Cosmetic Surgery.

“Liquid silicone is one of the most awesome fillers you can use, as long as you use it correctly,” said Dr. Shumway at the annual meeting of the American Academy of Cosmetic Surgery. He discussed silicone lip enhancement at the meeting jointly with Dr. Salvador Renteria, his colleague in private practice in La Jolla, Calif.

Using strategically placed microdroplets can produce “permanent, soft, and amazing” results with the correct technique, said Dr. Shumway. The only equipment needed is a 27 gauge needle and a 1 cc syringe, together with the purified liquid silicone material, technically termed polydimethylsiloxane. Silicone is also relatively cost effective for all involved, he said.

Free liquid silicone is only currently approved by the FDA for ophthalmic use, and it’s this formulation that is also used off-label for cosmetic procedures. The fact that cosmetic injection of liquid silicone is off label can present a marketing barrier, and physicians must be careful to adhere to state regulations regarding advertising off-label procedures.

For Dr. Renteria and Dr. Shumway, it also means that a special patient consent form must be used, and carefully reviewed with patients. “We go over this form with them about all the complications that can occur, that it is permanent, that it’s going to require more than one session,” said Dr. Renteria.

The injection technique involves beginning at the lateral commissures and proceeding toward the philtrum in an outline fashion with microdroplets, then adding some volume to the lips after the outline has been enhanced. “In particular, you can augment the philtrum, which gives anterior projection,” said Dr. Renteria. The total amount of liquid silicone injected per session is usually about 0.5 to 0.8 cc, he said.

Managing patient expectations is also important, said Dr. Renteria. “We have a fairly lengthy discussion about what their desires are,” he said.

The interval between injection sessions should be six to eight weeks, and multiple sessions may be required. This interval between treatment sessions allows fibroplasia to occur, so the tissue surrounding the silicone has a similar texture to the injected material. “You’re never going to try to achieve the goal in one session,” said Dr. Shumway.

“Each droplet’s going to grow, which is why you give it 6 to 8 weeks for that growth to occur and encapsulate around each droplet. That’s important, because you don’t get the final result for at least 2 months,” added Dr. Renteria.

Patient compliance with this schedule is essential: “You are the one who has to be in control” of the injection schedule, said Dr. Shumway. “If you’re patient, and your patient is patient, you can get excellent results.”

Dr. Shumway and Dr. Renteria reported no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

HOLLYWOOD, FL. – Less may be more when it comes to liquid silicone for lip enhancement.

Tiny droplets of silicone, placed judiciously and built up gradually, can give a soft, natural, permanent effect, according to Dr. Robert Shumway, president of the American Academy of Cosmetic Surgery.

“Liquid silicone is one of the most awesome fillers you can use, as long as you use it correctly,” said Dr. Shumway at the annual meeting of the American Academy of Cosmetic Surgery. He discussed silicone lip enhancement at the meeting jointly with Dr. Salvador Renteria, his colleague in private practice in La Jolla, Calif.

Using strategically placed microdroplets can produce “permanent, soft, and amazing” results with the correct technique, said Dr. Shumway. The only equipment needed is a 27 gauge needle and a 1 cc syringe, together with the purified liquid silicone material, technically termed polydimethylsiloxane. Silicone is also relatively cost effective for all involved, he said.

Free liquid silicone is only currently approved by the FDA for ophthalmic use, and it’s this formulation that is also used off-label for cosmetic procedures. The fact that cosmetic injection of liquid silicone is off label can present a marketing barrier, and physicians must be careful to adhere to state regulations regarding advertising off-label procedures.

For Dr. Renteria and Dr. Shumway, it also means that a special patient consent form must be used, and carefully reviewed with patients. “We go over this form with them about all the complications that can occur, that it is permanent, that it’s going to require more than one session,” said Dr. Renteria.

The injection technique involves beginning at the lateral commissures and proceeding toward the philtrum in an outline fashion with microdroplets, then adding some volume to the lips after the outline has been enhanced. “In particular, you can augment the philtrum, which gives anterior projection,” said Dr. Renteria. The total amount of liquid silicone injected per session is usually about 0.5 to 0.8 cc, he said.

Managing patient expectations is also important, said Dr. Renteria. “We have a fairly lengthy discussion about what their desires are,” he said.

The interval between injection sessions should be six to eight weeks, and multiple sessions may be required. This interval between treatment sessions allows fibroplasia to occur, so the tissue surrounding the silicone has a similar texture to the injected material. “You’re never going to try to achieve the goal in one session,” said Dr. Shumway.

“Each droplet’s going to grow, which is why you give it 6 to 8 weeks for that growth to occur and encapsulate around each droplet. That’s important, because you don’t get the final result for at least 2 months,” added Dr. Renteria.

Patient compliance with this schedule is essential: “You are the one who has to be in control” of the injection schedule, said Dr. Shumway. “If you’re patient, and your patient is patient, you can get excellent results.”

Dr. Shumway and Dr. Renteria reported no relevant financial disclosures.

koakes@frontlinemedcom.com

On Twitter @karioakes

In 1983 the Brazilian Ministry of Health launched the Program for Integrated Women’s Health Care following a worldwide trend to adopt multidisciplinary approaches that consider the complexity of women’s health.¹ Although menopause may have the greatest impact on women’s health among all the stages of life, research on this topic is limited.² Due to the aging general population, both the proportion of women who are menopausal and the total population of menopausal women have increased.² On average, women in developed countries spend one-third of their lives in menopause; thus, the physiology of menopause has become a matter of public health. In a survey of 87 women attending a specialist menopause clinic, more than 64% reported prior skin problems.³ Despite the high frequency of dermatologic signs and symptoms associated with menopause, few studies have been conducted on the subject.^3,4 In this article, we review some of the common skin disorders that occur during menopause and assess possible therapeutic and preventive skin care approaches.

Stages of Menopause

During perimenopause, irregular menstrual cycles and a series of clinical manifestations occur⁵ that may precede menopause by 2 to 8 years.⁶ The term menopausal transition is used by the World Health Organization to describe the phase of perimenopause prior to the end of menstrual periods.⁷ The World Health Organization also suggests that the term climacterium should be substituted for perimenopause in the period ranging from just before the onset of menopause to 1 year after menopause. Climacterium is the period of transition between the last years of the reproductive stage and postreproductive life, which begins with the gradual disappearance of ovarian function.⁸

Menopause is the cessation of menstrual periods due to the loss of ovarian function and is a normal physiologic process in women when it occurs after the fifth decade of life. The mean age at menopause is 51 years, and the clinical criterion used to establish the diagnosis is complete absence of menstrual periods for 12 months.⁶

Throughout a woman’s life, the total number of primordial ovarian follicles decreases and most become refractory to the actions of pituitary gonadotropins. As a result, the circulating level of estradiol progressively decreases and progesterone production by the corpus luteum becomes irregular and subsequently ceases.⁸ Increased production of follicle-stimulating hormone and luteinizing hormone occurs as a consequence. Conversely, the changes in circulating androgens are more complex and controversial.⁹ It has been documented that testosterone production is lower in postmenopausal patients and that sex hormone–binding globulin decreases and the free androgen index increases.Dehydroepiandrosterone sulfate linearly declines as a function of age, but it lacks an obvious relationship with ovarian function.¹⁰

The Importance of Hormones on the Skin

Ovarian failure and the resulting hormonal changes during menopause affect almost all aspects of women’s health and may present with signs and symptoms in nearly every body system.⁵ Symptoms are experienced differently according to ethnic, educational, and sociocultural variability. Asian American women report a low frequency of physical, psychological, and psychosomatic symptoms compared with black women.¹¹ Brazilian women have a higher prevalence of vasomotor symptoms compared to women in other developed Western countries.¹² Also, medications used during perimenopause to prevent and treat osteoporosis are capable of inducing hot flashes.¹³

Estrogens are essential for skin hydration because they increase production of glycosaminoglycans, promote an increased production of sebum, increase water retention, improve barrier function of the stratum corneum, and optimize the surface area of corneocytes. As a result, concerns about dry skin are more frequent among menopausal women who are not taking hormone replacement therapy (HRT).² Decreased estrogen reduces the polymerization of glycosaminoglycans, while elastin experiences granular degeneration and fragmentation, forming cystic spaces. In addition, there is a reduction in the microvasculature and thinning of the epidermis.^14,15

Albright et al¹⁶ noted that the skin of menopausal women with osteoporosis showed considerable atrophy, a finding subsequently supported by a study from Brincat et al.¹⁷ In menopausal women, the decrease in estrogen promotes a reduction in type I and type III collagen and a reduction in the type III collagen to type I collagen ratio compared with nonmenopausal women.¹⁸ Healthy skin is made up of type I collagen (80%, responsible for strength) to type III collagen (15%, responsible for elasticity).² However, a decrease in androgens is partially responsible for the reduction in sebum secretion, xerosis, and skin thinning or atrophy, accompanied by a reduction in blood vessels, oxygenation, and nutrition of the skin, as well as increased transepidermal water loss.^19,20 Regarding skin annexes, the decrease in estrogen causes a reduction in axillary and pubic hair. The reduction in elastic fibers results in a loss of firmness and elasticity. Moreover, with a relative predominance of androgenic hormones, vellus hair may be replaced by thicker hair.²¹

Anagen hairs have estrogen receptors in both sexes. In contrast to the α-receptor, the β-receptor largely is expressed in the papillary dermis and the hair’s bulb region; this expression could account for the occurrence of androgenetic alopecia in menopausal women. These receptors are not expressed in telogen hairs, and their role in regulating the hair cycle is unknown.²⁰ The aging of the follicular unit, resulting from the reduction of active melanocytes, promotes the appearance of gray hair. It is estimated that in 50% of men and women, half of their hair will be gray by 50 years of age.²¹ The age of onset for graying hair appears to be influenced by heredity and ethnicity. Unlike the skin, hair aging is more affected by intrinsic than extrinsic factors.^22,23

In women, hormonal changes during menopause are the main source of alterations in hair characteristics.²⁴ The identification of high concentrations of hydrogen peroxide and low levels of catalase in the stems of gray hairs have shed light on the biochemistry of hair whitening and opened new possibilities for its prevention and treatment. A change in the balance of oxidation/reduction reactions may lead to DNA damage and melanocyte apoptosis.^22,25

Osteoporosis and Vitamin D

Concerns about the worsening of or induction of osteoporosis after menopause due to the excessive use of sunscreens and vitamin D (VD) deficiency are controversial. Middle-aged women with low serum 25-hydroxyvitamin D levels (<20 ng/mL) have an increased risk of fracture during menopausal transition.²⁶ A study that measured the UV index in São Paulo, Brazil, demonstrated that environmental levels ensure sufficient production of VD from unintentional sun exposure throughout the course of the year.²⁷ Thus, concerns about the use of sunscreen affecting VD levels are not justified.^27,28

In a study that specifically focused on postmenopausal women in Recife, Brazil (which is located 10º south of the equator), a considerable prevalence of VD deficiency was found, ranging from 30% to 83% depending on age. Despite the abundance of sunlight, the researchers emphasized that the VD prevalence rates found in the study were similar to those observed in nontropical countries, such as the United States and Canada; however, the period of intentional exposure to the sun was not assessed.²⁹ Moreover, the lack of consensus on the appropriate levels of sun exposure makes it difficult to compare different countries, and thus it is recommended that minimum normal limits be regionally established.^29,30

Although it has been suggested that the use of sun protection factor 15 could, in theory, promote a 99% reduction in the synthesis of VD, other studies have failed to identify such an insufficiency.^31,32 In practice, the disparity may be explained by the large variation in the amount of sunscreen applied, by the body areas to which it is applied, and by the fact that duration of sun exposure usually is greater when using sunscreen.³¹

Considering all the evidence and taking into account that the safe limit for sun exposure that allows maximum synthesis of VD without an increased risk for skin cancer remains unknown, the American Academy of Dermatology states that intentional exposure to the sun should not be considered a main source of sun exposure and the use of sunscreen should not be discouraged. Instead, the Academy recommends using dietary sources of VD or artificial VD supplementation at doses that vary by age: between 1 and 70 years, a dose of 600 IU daily is recommended; older than 70 years, 800 IU daily.³³

Primary Skin Disorders of Menopause

Pruritus

Pruritus is the primary skin concern in women older than 65 years. Given that xerosis is the most prominent cause of pruritus, consider the possible role of menopause-related transepidermal water loss.^19,34 Regardless of the underlying cause, however, some general measures are recommended for managing pruritus in menopausal women such as using low-pH moisturizers daily, preferably after bathing; keeping nails short; wearing loose and light clothing; maintaining a comfortable ambient temperature; using humidifiers or air-conditioning devices; restricting bathing time; and avoiding hot water and high-pH sanitizers.³⁴

Hyperhidrosis

Night sweats, hyperhidrosis, and hot flashes (flushing) are common concerns in 35% to 50% of perimenopausal women and in 30% to 80% of postmenopausal women.Menopausal hyperhidrosis is classified as secondary hyperhidrosis, the symptoms of which may be alleviated by HRT, suggesting that the cause is decreasing levels of estrogen.³⁵

In addition to HRT, other treatments such as gabapentin, serotonin-norepinephrine reuptake inhibitors, and acupuncture are used to treat menopausal hyperhidrosis. One study evaluated the use of oxybutynin for 3 months in 21 patients with menopausal hyperhidrosis, and the authors concluded that the drug was effective and well tolerated in women who were nonresponsive to HRT.³⁶

Senile Alopecia

Starting at 50 years of age, scalp hairs show varying degrees of change in pigmentation, growth, and diameter. Despite the normal ratio of telogen to anagen hair, there may be a considerable reduction in follicular density. The clinical distinction between senile alopecia and androgenetic alopecia can be challenging, and the conditions may coexist.²⁴

Androgenetic Alopecia

Up to 50% of women experience androgenetic alopecia, or female pattern hair loss (FPHL), during their lives.²⁴ It is the main cause of hair loss in women, and women in perimenopause are the most affected. Hair regrowth is difficult when treatment is not instituted early in perimenopausal FPHL.²⁴ The pathogenesis involves a progressive reduction in the hair cycle, resulting in shrinkage of the hair follicles.³⁷ Unlike the pathogenesis of androgenetic alopecia in men, little is known about the role of androgens in FPHL.³⁷ The measurement of androgen levels is not recommended in the absence of symptoms of virilization or in the absence of abnormal clinical patterns or progression.²⁴

Three clinical forms of FPHL have been described: (1) Ludwig classification (diffuse central thinning concentrated in the parieto-occipital region with the frontal hairline intact), (2) Olsen classification (thinning of the central line and a consequent Christmas tree pattern), and (3) Hamilton classification (frontotemporal or vertex recession, which is seen less often than the other 2 forms). Female pattern hair loss primarily is treated with a 2% to 5% minoxidil solution,³⁸ which is able to interrupt hair loss or induce mild to moderate regrowth in 60% of patients with FPHL.³⁷ The effectiveness of the treatment should only be assessed after 1 year of use.³⁷ Contact dermatitis is the main adverse effect, but its incidence may be reduced by up to 82% by using vehicles that do not contain propylene glycol.³⁹ If the use of minoxidil solution is not possible, good results also have been reported with antiandrogen medications, such as spironolactone.⁴⁰ These drugs are especially useful in cases of hyperandrogenism.³⁷

Conventional doses of finasteride 1 mg daily, as used in men, have shown discrepant results in menopausal women.^41-45 Improvement of FPHL has been shown in studies using doses of 2.5 mg or higher for a minimum of 12 months.^42-45 The use of dutasteride, an inhibitor of 5α-reductases I and II, promotes greater inhibition (100%) of dihydrotestosterone activity than finasteride (70%) in men; however, it has not yet been approved by the US Food and Drug Administration for treatment in women.⁴⁶

Impaired Wound Healing

Wound healing also is affected by aging. Delays in healing may be more closely related to the decrease in estrogen levels than to intrinsic aging. A comparison between the expression of genes associated with healing in young and elderly men showed that most of the genes are regulated exclusively by estrogen, which could explain the higher incidence of chronic ulcers in elderly men compared to women.⁴⁷ However, menopausal women also are at risk for development of chronic ulcers.⁴⁸ Ashcroft et al⁴⁹ showed that the use of topical estrogen accelerates the healing of acute incisional wounds by increasing transforming growth factor β.

Healing of the oral mucosa is associated with a higher rate of complications and longer recovery time in women than in men. Estrogens produce anti-inflammatory effects, whereas progesterone demonstrates a proinflammatory effect. Testosterone has anti-inflammatory effects and is able to modify the proinflammatory state in the oral mucosae of menopausal women. Wound healing in menopausal women who are not receiving HRT tends to be slower than in those who are receiving HRT. Age is not necessarily an important factor in wound healing. Premenopausal and younger women have shown no notable differences in healing. Nevertheless, after menopause, differences in wound healing have been found, indicating that hormonal status may be more crucial to wound healing than age.⁵⁰

Common Dermatoses With No Hormonal Associations

Brittle Nail Syndrome

Brittle nail syndrome (BNS) affects 20% of the population with a female-to-male ratio of 2:1.The pathogenesis of BNS involves factors that affect the adhesion of corneocytes to the nail plate and alter nail formation from its matrix; the former process produces onychoschizia, whereas the latter leads to onychorrhexis.⁵¹

The normal nail contains approximately 18% water, and nails with less than 16% water content are more likely to develop weakness.⁵² Nail water content appears to be negatively influenced by repetitive occupational exposure to water, and its increase is proportional to the frequency of moisturizer use. The use of certain nail polishes and cuticle removers is considered one of the main reasons for nail weakness in those who have frequent manicures.⁵³

Management of BNS requires the correction of the precipitating cause by hydration of the nail blade, cuticle, and proximal nail folds, preferably under occlusion. Supplementation with biotin is considered highly effective by many researchers.^54,55 In a retrospective study, the use of biotin for 6 months improved BNS in 63% (22/35) of patients.⁵⁶ Recommended doses generally are more than 2.5 mg daily.⁵⁷ The use of 10% urea in nail polish once or twice daily showed that both regimens improved the morphology, consistency, and reflectiveness of the nail plate.⁵²

The use of nail polish containing hydroxypropyl chitosan, Equisetum arvense extract, and methylsulfonylmethane has been reported as a treatment of dystrophic and fragile fingernails. The treatment was evaluated in patients with nail psoriasis and it was shown to be effective in decreasing dystrophy.⁵⁸

Although women are affected twice as frequently as men,⁵¹ there are no known studies comparing the prevalence of BNS in premenopausal versus menopausal women, despite the fact that the ratio of women to men affected has been shown to increase with age.^51,52 In our clinical practice, BNS predominates among menopausal women. We believe that low estrogen levels may lead to dehydration of the nail plate.

Frontal Fibrosing Alopecia

Frontal fibrosing alopecia has a tendency to affect menopausal women.⁵⁹ Frontal fibrosing alopecia is a slow, progressive, lymphocytic cicatricial alopecia that produces symmetrical frontal or temporal recession but rarely affects other areas of the scalp. It often is associated with nonscarring alopecia of body hair or eyebrows. The cicatricial area is atrophic, pale, and surrounded by hyperpigmented skin due to long-term sun damage.^60,61

Many investigators believe it is a variant of lichen planopilaris.^62,63 Others suggest the possibility that hormonal changes characteristic of perimenopause contribute to triggering the disease. Some cases show a partial response to finasteride or dutasteride.⁶⁴ Furthermore, the lymphocytic inflammatory component of the disorder has been treated with immunomodulators, topical and intralesional corticosteroids, and hydroxychloroquine.^60,63

Telogen Effluvium

Telogen effluvium (TE) is the premature transformation of hair from the anagen phase to the telogen phase. Considered a symptom of an underlying condition (eg, endocrine, nutritional, and autoimmune disorders) rather than a full diagnosis in itself,⁶⁵ TE is characterized by diffuse hair loss confirmed by a pull test in which more than 5 hairs are removed from the scalp on tugging a section of 25 to 50 hairs.⁶⁶ If there is concurrent TE in women with androgenetic alopecia, more severe hair loss has been reported.^24,66 There may be concerns of dysesthesia of the scalp (trichodynia), especially in patients with emotional stress.⁶⁶

Most often diagnosed in women, TE in its acute form is even more common in menopausal women and lasts less than 6 months.²⁴ The acute form of TE is secondary to hemorrhage, high fever, surgery, drug use, systemic diseases, diet, or great psychological stress and typically occurs 1 to 3 months after the primary event.^24,66 The most common cause of iron deficiency at menopausal transition is malabsorption or chronic gastrointestinal bleeding. Ferritin levels below 40 µg/L are associated withhair loss with a 98% specificity and sensitivity.²⁴ Low serum levels of vitamin B₁₂ or VD also are considered important factors.^24,65,66

Chronic TE (ie, lasting more than 6 months) predominantly occurs in women aged 40 to 60 years, and its onset is abrupt. Chronic TE is considered a diagnosis of exclusion.²⁴ In 30% of cases of chronic diffuse hair loss lasting longer than 6 months, the cause is unknown.⁶⁷ The pathogenesis is poorly understood, though it is assumed to result from a reduced duration of the anagen growth phase in the absence of shrinking hair follicles.^37,68

Patient education is the most important aspect of TE management. The aim of treatment is to reduce hair loss and correct the precipitating factors. Even if the underlying cause is corrected, hair loss may continue for up to 6 months with the desired cosmetic regrowth occurring after only 12 to 18 months.^37,65 In acute secondary TE, the course of the disease is self-limited, and correction of the causal factor is sufficient. In chronic diffuse loss, identification of causal factors is more difficult and treatment involves adequate nutrition (ie, at least 1200 calories daily including 9.8 mg/kg body weight of protein) and multivitamin supplementation, minoxidil, and even antiandrogen medications.^37,65-67

Trichotillomania

Trichotillomania is the compulsive behavior of plucking strands of hair and is considered to be a poor adaptive response to stress. Although trichotillomania most commonly occurs in children, adolescents, and young adults, in older adults it is more often associated with psychopathology and is markedly more common in women.⁶⁹ The condition usually is refractory to treatment, and although the scalp usually is the primary focus of the behavior, eventually patients may pluck body hair. Menopausal women also may present with trichoteiromania in which hair loss is secondary to repeated friction that has fractured the hair shaft; this condition often is associated with scalp dysesthesia.²⁴ Trichotillomania is considered an obsessive-compulsive disorder, whereas trichoteiromania needs further investigation because it can occur secondary to many psychiatric disorders. The specific psychotherapeutic and pharmacologic treatments likely will depend on the underlying cause of the disease.⁷⁰

Treatment of Skin Disorders in Menopausal Women

Classic HRT

Several studies have used histologic analysis or ultrasonography to show that estrogens used in HRT thicken the skin or increase collagen content, whether given orally, topically, or transdermally.^71-75 In a randomized, double-blind study comparing topical estrogen versus glycolic acid, 6 months of estrogen use on only one side of the face promoted a 23% increase in epidermal thickness (P=.00458), and the use of glycolic acid stimulated a 27% increase (P=.00467). The combined use of estrogen and glycolic acid prompted a 38% increase in epidermal thickness (P=.000181), with significant differences observed for all groups compared with the controls for the reversal of histologic markers of skin aging.⁷⁶

Finally, collagen synthesis also is increased as inferred by the increase in procollagen type I and II terminal peptides.⁷⁵ Hormone replacement therapy also affects the skin’s ability to retain water and leads to a reduction in skin wrinkling; however, the effects of HRT on dyschromic alterations have not been well studied.⁷⁷ The numerous adverse effects of HRT, such as an increased incidence of cancer and cardiovascular morbidity, limit its use.

Isoflavones

Estrogen use is capable of causing morphologic changes in the aged skin of menopausal women.^19,77 Given that HRT is contraindicated for some women and can cause adverse effects or pose unacceptable risks for others, Accorsi-Neto et al¹⁵ studied the possibility of achieving the beneficial effects of estrogen with plant hormones. Oral isoflavones given to rats that had been irradiated with UV light inhibited the increased expression of UV-induced metalloproteinases, reducing collagen degradation.⁷⁸

Among the phytoestrogens, genistein, an isoflavone, is notable for its selectivity, with a high affinity for estrogen receptor β and low affinity for estrogen receptor α, which is found in the uterus and breasts. Accorsi-Neto et al¹⁵ assessed whether soy isoflavones also would reduce skin aging in women, as observed in the aforementioned rat study. After 6 months of using 100 mg of concentrated soy extract daily, the investigators noted increased thickness of the dermis and epidermis, increased dermal vasculature, an increased number of collagen and elastic fibers, and an increased papillary index. In rats, genistein increases antioxidant enzymes, such as superoxide dismutase, catalase, and glutathione.^78,79 Topical phytoestrogens also were evaluated, with promising results for increased skin thickness. In animals, the use of isoflavones also offers protection against carcinogenesis in sun-damaged skin.¹⁵

Some investigators believe that a better understanding of the mechanism of action and possible side effects of phytoestrogens is essential to allow their use as a promising antiaging alternative.⁸⁰ There is no evidence that estrogens (eg, HRT) possess antioxidant or photoprotective properties.⁷⁸ Moreover, it is possible that new selective estrogen receptor modulators will specifically affect the skin without the expected systemic effects of existing estrogens.⁸⁰

Conclusion

Although often overlooked, skin disorders are quite common during menopause. Understanding the physiology of this important period in a woman’s life is essential for developing an early and effective preventive therapeutic approach. Use of sunscreens has been questioned due to a concern about osteoporosis, but studies have not shown a connection between sunscreen use and reduced VD levels. Intentional sun exposure should not be considered a source of VD; instead, recommend dietary or artificial supplementation. Although studies have shown HRT to positively affect wound healing, reduce signs of aging, increase hydration, and yield other benefits, its use is not recommended for treating skin disorders. Isoflavones could be promising alternatives to estrogen; however, further studies are needed before their use can be recommended.

In 1983 the Brazilian Ministry of Health launched the Program for Integrated Women’s Health Care following a worldwide trend to adopt multidisciplinary approaches that consider the complexity of women’s health.¹ Although menopause may have the greatest impact on women’s health among all the stages of life, research on this topic is limited.² Due to the aging general population, both the proportion of women who are menopausal and the total population of menopausal women have increased.² On average, women in developed countries spend one-third of their lives in menopause; thus, the physiology of menopause has become a matter of public health. In a survey of 87 women attending a specialist menopause clinic, more than 64% reported prior skin problems.³ Despite the high frequency of dermatologic signs and symptoms associated with menopause, few studies have been conducted on the subject.^3,4 In this article, we review some of the common skin disorders that occur during menopause and assess possible therapeutic and preventive skin care approaches.

Stages of Menopause

During perimenopause, irregular menstrual cycles and a series of clinical manifestations occur⁵ that may precede menopause by 2 to 8 years.⁶ The term menopausal transition is used by the World Health Organization to describe the phase of perimenopause prior to the end of menstrual periods.⁷ The World Health Organization also suggests that the term climacterium should be substituted for perimenopause in the period ranging from just before the onset of menopause to 1 year after menopause. Climacterium is the period of transition between the last years of the reproductive stage and postreproductive life, which begins with the gradual disappearance of ovarian function.⁸

Menopause is the cessation of menstrual periods due to the loss of ovarian function and is a normal physiologic process in women when it occurs after the fifth decade of life. The mean age at menopause is 51 years, and the clinical criterion used to establish the diagnosis is complete absence of menstrual periods for 12 months.⁶

Throughout a woman’s life, the total number of primordial ovarian follicles decreases and most become refractory to the actions of pituitary gonadotropins. As a result, the circulating level of estradiol progressively decreases and progesterone production by the corpus luteum becomes irregular and subsequently ceases.⁸ Increased production of follicle-stimulating hormone and luteinizing hormone occurs as a consequence. Conversely, the changes in circulating androgens are more complex and controversial.⁹ It has been documented that testosterone production is lower in postmenopausal patients and that sex hormone–binding globulin decreases and the free androgen index increases.Dehydroepiandrosterone sulfate linearly declines as a function of age, but it lacks an obvious relationship with ovarian function.¹⁰

The Importance of Hormones on the Skin

Ovarian failure and the resulting hormonal changes during menopause affect almost all aspects of women’s health and may present with signs and symptoms in nearly every body system.⁵ Symptoms are experienced differently according to ethnic, educational, and sociocultural variability. Asian American women report a low frequency of physical, psychological, and psychosomatic symptoms compared with black women.¹¹ Brazilian women have a higher prevalence of vasomotor symptoms compared to women in other developed Western countries.¹² Also, medications used during perimenopause to prevent and treat osteoporosis are capable of inducing hot flashes.¹³

Estrogens are essential for skin hydration because they increase production of glycosaminoglycans, promote an increased production of sebum, increase water retention, improve barrier function of the stratum corneum, and optimize the surface area of corneocytes. As a result, concerns about dry skin are more frequent among menopausal women who are not taking hormone replacement therapy (HRT).² Decreased estrogen reduces the polymerization of glycosaminoglycans, while elastin experiences granular degeneration and fragmentation, forming cystic spaces. In addition, there is a reduction in the microvasculature and thinning of the epidermis.^14,15

Albright et al¹⁶ noted that the skin of menopausal women with osteoporosis showed considerable atrophy, a finding subsequently supported by a study from Brincat et al.¹⁷ In menopausal women, the decrease in estrogen promotes a reduction in type I and type III collagen and a reduction in the type III collagen to type I collagen ratio compared with nonmenopausal women.¹⁸ Healthy skin is made up of type I collagen (80%, responsible for strength) to type III collagen (15%, responsible for elasticity).² However, a decrease in androgens is partially responsible for the reduction in sebum secretion, xerosis, and skin thinning or atrophy, accompanied by a reduction in blood vessels, oxygenation, and nutrition of the skin, as well as increased transepidermal water loss.^19,20 Regarding skin annexes, the decrease in estrogen causes a reduction in axillary and pubic hair. The reduction in elastic fibers results in a loss of firmness and elasticity. Moreover, with a relative predominance of androgenic hormones, vellus hair may be replaced by thicker hair.²¹

Anagen hairs have estrogen receptors in both sexes. In contrast to the α-receptor, the β-receptor largely is expressed in the papillary dermis and the hair’s bulb region; this expression could account for the occurrence of androgenetic alopecia in menopausal women. These receptors are not expressed in telogen hairs, and their role in regulating the hair cycle is unknown.²⁰ The aging of the follicular unit, resulting from the reduction of active melanocytes, promotes the appearance of gray hair. It is estimated that in 50% of men and women, half of their hair will be gray by 50 years of age.²¹ The age of onset for graying hair appears to be influenced by heredity and ethnicity. Unlike the skin, hair aging is more affected by intrinsic than extrinsic factors.^22,23

In women, hormonal changes during menopause are the main source of alterations in hair characteristics.²⁴ The identification of high concentrations of hydrogen peroxide and low levels of catalase in the stems of gray hairs have shed light on the biochemistry of hair whitening and opened new possibilities for its prevention and treatment. A change in the balance of oxidation/reduction reactions may lead to DNA damage and melanocyte apoptosis.^22,25

Osteoporosis and Vitamin D

Concerns about the worsening of or induction of osteoporosis after menopause due to the excessive use of sunscreens and vitamin D (VD) deficiency are controversial. Middle-aged women with low serum 25-hydroxyvitamin D levels (<20 ng/mL) have an increased risk of fracture during menopausal transition.²⁶ A study that measured the UV index in São Paulo, Brazil, demonstrated that environmental levels ensure sufficient production of VD from unintentional sun exposure throughout the course of the year.²⁷ Thus, concerns about the use of sunscreen affecting VD levels are not justified.^27,28

In a study that specifically focused on postmenopausal women in Recife, Brazil (which is located 10º south of the equator), a considerable prevalence of VD deficiency was found, ranging from 30% to 83% depending on age. Despite the abundance of sunlight, the researchers emphasized that the VD prevalence rates found in the study were similar to those observed in nontropical countries, such as the United States and Canada; however, the period of intentional exposure to the sun was not assessed.²⁹ Moreover, the lack of consensus on the appropriate levels of sun exposure makes it difficult to compare different countries, and thus it is recommended that minimum normal limits be regionally established.^29,30

Although it has been suggested that the use of sun protection factor 15 could, in theory, promote a 99% reduction in the synthesis of VD, other studies have failed to identify such an insufficiency.^31,32 In practice, the disparity may be explained by the large variation in the amount of sunscreen applied, by the body areas to which it is applied, and by the fact that duration of sun exposure usually is greater when using sunscreen.³¹

Considering all the evidence and taking into account that the safe limit for sun exposure that allows maximum synthesis of VD without an increased risk for skin cancer remains unknown, the American Academy of Dermatology states that intentional exposure to the sun should not be considered a main source of sun exposure and the use of sunscreen should not be discouraged. Instead, the Academy recommends using dietary sources of VD or artificial VD supplementation at doses that vary by age: between 1 and 70 years, a dose of 600 IU daily is recommended; older than 70 years, 800 IU daily.³³

Primary Skin Disorders of Menopause

Pruritus

Pruritus is the primary skin concern in women older than 65 years. Given that xerosis is the most prominent cause of pruritus, consider the possible role of menopause-related transepidermal water loss.^19,34 Regardless of the underlying cause, however, some general measures are recommended for managing pruritus in menopausal women such as using low-pH moisturizers daily, preferably after bathing; keeping nails short; wearing loose and light clothing; maintaining a comfortable ambient temperature; using humidifiers or air-conditioning devices; restricting bathing time; and avoiding hot water and high-pH sanitizers.³⁴

Hyperhidrosis

Night sweats, hyperhidrosis, and hot flashes (flushing) are common concerns in 35% to 50% of perimenopausal women and in 30% to 80% of postmenopausal women.Menopausal hyperhidrosis is classified as secondary hyperhidrosis, the symptoms of which may be alleviated by HRT, suggesting that the cause is decreasing levels of estrogen.³⁵

In addition to HRT, other treatments such as gabapentin, serotonin-norepinephrine reuptake inhibitors, and acupuncture are used to treat menopausal hyperhidrosis. One study evaluated the use of oxybutynin for 3 months in 21 patients with menopausal hyperhidrosis, and the authors concluded that the drug was effective and well tolerated in women who were nonresponsive to HRT.³⁶

Senile Alopecia

Starting at 50 years of age, scalp hairs show varying degrees of change in pigmentation, growth, and diameter. Despite the normal ratio of telogen to anagen hair, there may be a considerable reduction in follicular density. The clinical distinction between senile alopecia and androgenetic alopecia can be challenging, and the conditions may coexist.²⁴

Androgenetic Alopecia

Up to 50% of women experience androgenetic alopecia, or female pattern hair loss (FPHL), during their lives.²⁴ It is the main cause of hair loss in women, and women in perimenopause are the most affected. Hair regrowth is difficult when treatment is not instituted early in perimenopausal FPHL.²⁴ The pathogenesis involves a progressive reduction in the hair cycle, resulting in shrinkage of the hair follicles.³⁷ Unlike the pathogenesis of androgenetic alopecia in men, little is known about the role of androgens in FPHL.³⁷ The measurement of androgen levels is not recommended in the absence of symptoms of virilization or in the absence of abnormal clinical patterns or progression.²⁴

Three clinical forms of FPHL have been described: (1) Ludwig classification (diffuse central thinning concentrated in the parieto-occipital region with the frontal hairline intact), (2) Olsen classification (thinning of the central line and a consequent Christmas tree pattern), and (3) Hamilton classification (frontotemporal or vertex recession, which is seen less often than the other 2 forms). Female pattern hair loss primarily is treated with a 2% to 5% minoxidil solution,³⁸ which is able to interrupt hair loss or induce mild to moderate regrowth in 60% of patients with FPHL.³⁷ The effectiveness of the treatment should only be assessed after 1 year of use.³⁷ Contact dermatitis is the main adverse effect, but its incidence may be reduced by up to 82% by using vehicles that do not contain propylene glycol.³⁹ If the use of minoxidil solution is not possible, good results also have been reported with antiandrogen medications, such as spironolactone.⁴⁰ These drugs are especially useful in cases of hyperandrogenism.³⁷

Conventional doses of finasteride 1 mg daily, as used in men, have shown discrepant results in menopausal women.^41-45 Improvement of FPHL has been shown in studies using doses of 2.5 mg or higher for a minimum of 12 months.^42-45 The use of dutasteride, an inhibitor of 5α-reductases I and II, promotes greater inhibition (100%) of dihydrotestosterone activity than finasteride (70%) in men; however, it has not yet been approved by the US Food and Drug Administration for treatment in women.⁴⁶

Impaired Wound Healing

Wound healing also is affected by aging. Delays in healing may be more closely related to the decrease in estrogen levels than to intrinsic aging. A comparison between the expression of genes associated with healing in young and elderly men showed that most of the genes are regulated exclusively by estrogen, which could explain the higher incidence of chronic ulcers in elderly men compared to women.⁴⁷ However, menopausal women also are at risk for development of chronic ulcers.⁴⁸ Ashcroft et al⁴⁹ showed that the use of topical estrogen accelerates the healing of acute incisional wounds by increasing transforming growth factor β.

Healing of the oral mucosa is associated with a higher rate of complications and longer recovery time in women than in men. Estrogens produce anti-inflammatory effects, whereas progesterone demonstrates a proinflammatory effect. Testosterone has anti-inflammatory effects and is able to modify the proinflammatory state in the oral mucosae of menopausal women. Wound healing in menopausal women who are not receiving HRT tends to be slower than in those who are receiving HRT. Age is not necessarily an important factor in wound healing. Premenopausal and younger women have shown no notable differences in healing. Nevertheless, after menopause, differences in wound healing have been found, indicating that hormonal status may be more crucial to wound healing than age.⁵⁰

Common Dermatoses With No Hormonal Associations

Brittle Nail Syndrome

Brittle nail syndrome (BNS) affects 20% of the population with a female-to-male ratio of 2:1.The pathogenesis of BNS involves factors that affect the adhesion of corneocytes to the nail plate and alter nail formation from its matrix; the former process produces onychoschizia, whereas the latter leads to onychorrhexis.⁵¹

The normal nail contains approximately 18% water, and nails with less than 16% water content are more likely to develop weakness.⁵² Nail water content appears to be negatively influenced by repetitive occupational exposure to water, and its increase is proportional to the frequency of moisturizer use. The use of certain nail polishes and cuticle removers is considered one of the main reasons for nail weakness in those who have frequent manicures.⁵³

Management of BNS requires the correction of the precipitating cause by hydration of the nail blade, cuticle, and proximal nail folds, preferably under occlusion. Supplementation with biotin is considered highly effective by many researchers.^54,55 In a retrospective study, the use of biotin for 6 months improved BNS in 63% (22/35) of patients.⁵⁶ Recommended doses generally are more than 2.5 mg daily.⁵⁷ The use of 10% urea in nail polish once or twice daily showed that both regimens improved the morphology, consistency, and reflectiveness of the nail plate.⁵²

The use of nail polish containing hydroxypropyl chitosan, Equisetum arvense extract, and methylsulfonylmethane has been reported as a treatment of dystrophic and fragile fingernails. The treatment was evaluated in patients with nail psoriasis and it was shown to be effective in decreasing dystrophy.⁵⁸

Although women are affected twice as frequently as men,⁵¹ there are no known studies comparing the prevalence of BNS in premenopausal versus menopausal women, despite the fact that the ratio of women to men affected has been shown to increase with age.^51,52 In our clinical practice, BNS predominates among menopausal women. We believe that low estrogen levels may lead to dehydration of the nail plate.

Frontal Fibrosing Alopecia

Frontal fibrosing alopecia has a tendency to affect menopausal women.⁵⁹ Frontal fibrosing alopecia is a slow, progressive, lymphocytic cicatricial alopecia that produces symmetrical frontal or temporal recession but rarely affects other areas of the scalp. It often is associated with nonscarring alopecia of body hair or eyebrows. The cicatricial area is atrophic, pale, and surrounded by hyperpigmented skin due to long-term sun damage.^60,61

Many investigators believe it is a variant of lichen planopilaris.^62,63 Others suggest the possibility that hormonal changes characteristic of perimenopause contribute to triggering the disease. Some cases show a partial response to finasteride or dutasteride.⁶⁴ Furthermore, the lymphocytic inflammatory component of the disorder has been treated with immunomodulators, topical and intralesional corticosteroids, and hydroxychloroquine.^60,63

Telogen Effluvium

Telogen effluvium (TE) is the premature transformation of hair from the anagen phase to the telogen phase. Considered a symptom of an underlying condition (eg, endocrine, nutritional, and autoimmune disorders) rather than a full diagnosis in itself,⁶⁵ TE is characterized by diffuse hair loss confirmed by a pull test in which more than 5 hairs are removed from the scalp on tugging a section of 25 to 50 hairs.⁶⁶ If there is concurrent TE in women with androgenetic alopecia, more severe hair loss has been reported.^24,66 There may be concerns of dysesthesia of the scalp (trichodynia), especially in patients with emotional stress.⁶⁶

Most often diagnosed in women, TE in its acute form is even more common in menopausal women and lasts less than 6 months.²⁴ The acute form of TE is secondary to hemorrhage, high fever, surgery, drug use, systemic diseases, diet, or great psychological stress and typically occurs 1 to 3 months after the primary event.^24,66 The most common cause of iron deficiency at menopausal transition is malabsorption or chronic gastrointestinal bleeding. Ferritin levels below 40 µg/L are associated withhair loss with a 98% specificity and sensitivity.²⁴ Low serum levels of vitamin B₁₂ or VD also are considered important factors.^24,65,66

Chronic TE (ie, lasting more than 6 months) predominantly occurs in women aged 40 to 60 years, and its onset is abrupt. Chronic TE is considered a diagnosis of exclusion.²⁴ In 30% of cases of chronic diffuse hair loss lasting longer than 6 months, the cause is unknown.⁶⁷ The pathogenesis is poorly understood, though it is assumed to result from a reduced duration of the anagen growth phase in the absence of shrinking hair follicles.^37,68

Patient education is the most important aspect of TE management. The aim of treatment is to reduce hair loss and correct the precipitating factors. Even if the underlying cause is corrected, hair loss may continue for up to 6 months with the desired cosmetic regrowth occurring after only 12 to 18 months.^37,65 In acute secondary TE, the course of the disease is self-limited, and correction of the causal factor is sufficient. In chronic diffuse loss, identification of causal factors is more difficult and treatment involves adequate nutrition (ie, at least 1200 calories daily including 9.8 mg/kg body weight of protein) and multivitamin supplementation, minoxidil, and even antiandrogen medications.^37,65-67

Trichotillomania

Trichotillomania is the compulsive behavior of plucking strands of hair and is considered to be a poor adaptive response to stress. Although trichotillomania most commonly occurs in children, adolescents, and young adults, in older adults it is more often associated with psychopathology and is markedly more common in women.⁶⁹ The condition usually is refractory to treatment, and although the scalp usually is the primary focus of the behavior, eventually patients may pluck body hair. Menopausal women also may present with trichoteiromania in which hair loss is secondary to repeated friction that has fractured the hair shaft; this condition often is associated with scalp dysesthesia.²⁴ Trichotillomania is considered an obsessive-compulsive disorder, whereas trichoteiromania needs further investigation because it can occur secondary to many psychiatric disorders. The specific psychotherapeutic and pharmacologic treatments likely will depend on the underlying cause of the disease.⁷⁰

Treatment of Skin Disorders in Menopausal Women

Classic HRT

Several studies have used histologic analysis or ultrasonography to show that estrogens used in HRT thicken the skin or increase collagen content, whether given orally, topically, or transdermally.^71-75 In a randomized, double-blind study comparing topical estrogen versus glycolic acid, 6 months of estrogen use on only one side of the face promoted a 23% increase in epidermal thickness (P=.00458), and the use of glycolic acid stimulated a 27% increase (P=.00467). The combined use of estrogen and glycolic acid prompted a 38% increase in epidermal thickness (P=.000181), with significant differences observed for all groups compared with the controls for the reversal of histologic markers of skin aging.⁷⁶

Finally, collagen synthesis also is increased as inferred by the increase in procollagen type I and II terminal peptides.⁷⁵ Hormone replacement therapy also affects the skin’s ability to retain water and leads to a reduction in skin wrinkling; however, the effects of HRT on dyschromic alterations have not been well studied.⁷⁷ The numerous adverse effects of HRT, such as an increased incidence of cancer and cardiovascular morbidity, limit its use.

Isoflavones

Estrogen use is capable of causing morphologic changes in the aged skin of menopausal women.^19,77 Given that HRT is contraindicated for some women and can cause adverse effects or pose unacceptable risks for others, Accorsi-Neto et al¹⁵ studied the possibility of achieving the beneficial effects of estrogen with plant hormones. Oral isoflavones given to rats that had been irradiated with UV light inhibited the increased expression of UV-induced metalloproteinases, reducing collagen degradation.⁷⁸

Among the phytoestrogens, genistein, an isoflavone, is notable for its selectivity, with a high affinity for estrogen receptor β and low affinity for estrogen receptor α, which is found in the uterus and breasts. Accorsi-Neto et al¹⁵ assessed whether soy isoflavones also would reduce skin aging in women, as observed in the aforementioned rat study. After 6 months of using 100 mg of concentrated soy extract daily, the investigators noted increased thickness of the dermis and epidermis, increased dermal vasculature, an increased number of collagen and elastic fibers, and an increased papillary index. In rats, genistein increases antioxidant enzymes, such as superoxide dismutase, catalase, and glutathione.^78,79 Topical phytoestrogens also were evaluated, with promising results for increased skin thickness. In animals, the use of isoflavones also offers protection against carcinogenesis in sun-damaged skin.¹⁵

Some investigators believe that a better understanding of the mechanism of action and possible side effects of phytoestrogens is essential to allow their use as a promising antiaging alternative.⁸⁰ There is no evidence that estrogens (eg, HRT) possess antioxidant or photoprotective properties.⁷⁸ Moreover, it is possible that new selective estrogen receptor modulators will specifically affect the skin without the expected systemic effects of existing estrogens.⁸⁰

Conclusion

Although often overlooked, skin disorders are quite common during menopause. Understanding the physiology of this important period in a woman’s life is essential for developing an early and effective preventive therapeutic approach. Use of sunscreens has been questioned due to a concern about osteoporosis, but studies have not shown a connection between sunscreen use and reduced VD levels. Intentional sun exposure should not be considered a source of VD; instead, recommend dietary or artificial supplementation. Although studies have shown HRT to positively affect wound healing, reduce signs of aging, increase hydration, and yield other benefits, its use is not recommended for treating skin disorders. Isoflavones could be promising alternatives to estrogen; however, further studies are needed before their use can be recommended.

In 1983 the Brazilian Ministry of Health launched the Program for Integrated Women’s Health Care following a worldwide trend to adopt multidisciplinary approaches that consider the complexity of women’s health.¹ Although menopause may have the greatest impact on women’s health among all the stages of life, research on this topic is limited.² Due to the aging general population, both the proportion of women who are menopausal and the total population of menopausal women have increased.² On average, women in developed countries spend one-third of their lives in menopause; thus, the physiology of menopause has become a matter of public health. In a survey of 87 women attending a specialist menopause clinic, more than 64% reported prior skin problems.³ Despite the high frequency of dermatologic signs and symptoms associated with menopause, few studies have been conducted on the subject.^3,4 In this article, we review some of the common skin disorders that occur during menopause and assess possible therapeutic and preventive skin care approaches.

Stages of Menopause

During perimenopause, irregular menstrual cycles and a series of clinical manifestations occur⁵ that may precede menopause by 2 to 8 years.⁶ The term menopausal transition is used by the World Health Organization to describe the phase of perimenopause prior to the end of menstrual periods.⁷ The World Health Organization also suggests that the term climacterium should be substituted for perimenopause in the period ranging from just before the onset of menopause to 1 year after menopause. Climacterium is the period of transition between the last years of the reproductive stage and postreproductive life, which begins with the gradual disappearance of ovarian function.⁸

Menopause is the cessation of menstrual periods due to the loss of ovarian function and is a normal physiologic process in women when it occurs after the fifth decade of life. The mean age at menopause is 51 years, and the clinical criterion used to establish the diagnosis is complete absence of menstrual periods for 12 months.⁶

Throughout a woman’s life, the total number of primordial ovarian follicles decreases and most become refractory to the actions of pituitary gonadotropins. As a result, the circulating level of estradiol progressively decreases and progesterone production by the corpus luteum becomes irregular and subsequently ceases.⁸ Increased production of follicle-stimulating hormone and luteinizing hormone occurs as a consequence. Conversely, the changes in circulating androgens are more complex and controversial.⁹ It has been documented that testosterone production is lower in postmenopausal patients and that sex hormone–binding globulin decreases and the free androgen index increases.Dehydroepiandrosterone sulfate linearly declines as a function of age, but it lacks an obvious relationship with ovarian function.¹⁰

The Importance of Hormones on the Skin

Ovarian failure and the resulting hormonal changes during menopause affect almost all aspects of women’s health and may present with signs and symptoms in nearly every body system.⁵ Symptoms are experienced differently according to ethnic, educational, and sociocultural variability. Asian American women report a low frequency of physical, psychological, and psychosomatic symptoms compared with black women.¹¹ Brazilian women have a higher prevalence of vasomotor symptoms compared to women in other developed Western countries.¹² Also, medications used during perimenopause to prevent and treat osteoporosis are capable of inducing hot flashes.¹³

Estrogens are essential for skin hydration because they increase production of glycosaminoglycans, promote an increased production of sebum, increase water retention, improve barrier function of the stratum corneum, and optimize the surface area of corneocytes. As a result, concerns about dry skin are more frequent among menopausal women who are not taking hormone replacement therapy (HRT).² Decreased estrogen reduces the polymerization of glycosaminoglycans, while elastin experiences granular degeneration and fragmentation, forming cystic spaces. In addition, there is a reduction in the microvasculature and thinning of the epidermis.^14,15

Albright et al¹⁶ noted that the skin of menopausal women with osteoporosis showed considerable atrophy, a finding subsequently supported by a study from Brincat et al.¹⁷ In menopausal women, the decrease in estrogen promotes a reduction in type I and type III collagen and a reduction in the type III collagen to type I collagen ratio compared with nonmenopausal women.¹⁸ Healthy skin is made up of type I collagen (80%, responsible for strength) to type III collagen (15%, responsible for elasticity).² However, a decrease in androgens is partially responsible for the reduction in sebum secretion, xerosis, and skin thinning or atrophy, accompanied by a reduction in blood vessels, oxygenation, and nutrition of the skin, as well as increased transepidermal water loss.^19,20 Regarding skin annexes, the decrease in estrogen causes a reduction in axillary and pubic hair. The reduction in elastic fibers results in a loss of firmness and elasticity. Moreover, with a relative predominance of androgenic hormones, vellus hair may be replaced by thicker hair.²¹

Anagen hairs have estrogen receptors in both sexes. In contrast to the α-receptor, the β-receptor largely is expressed in the papillary dermis and the hair’s bulb region; this expression could account for the occurrence of androgenetic alopecia in menopausal women. These receptors are not expressed in telogen hairs, and their role in regulating the hair cycle is unknown.²⁰ The aging of the follicular unit, resulting from the reduction of active melanocytes, promotes the appearance of gray hair. It is estimated that in 50% of men and women, half of their hair will be gray by 50 years of age.²¹ The age of onset for graying hair appears to be influenced by heredity and ethnicity. Unlike the skin, hair aging is more affected by intrinsic than extrinsic factors.^22,23

In women, hormonal changes during menopause are the main source of alterations in hair characteristics.²⁴ The identification of high concentrations of hydrogen peroxide and low levels of catalase in the stems of gray hairs have shed light on the biochemistry of hair whitening and opened new possibilities for its prevention and treatment. A change in the balance of oxidation/reduction reactions may lead to DNA damage and melanocyte apoptosis.^22,25

Osteoporosis and Vitamin D

Concerns about the worsening of or induction of osteoporosis after menopause due to the excessive use of sunscreens and vitamin D (VD) deficiency are controversial. Middle-aged women with low serum 25-hydroxyvitamin D levels (<20 ng/mL) have an increased risk of fracture during menopausal transition.²⁶ A study that measured the UV index in São Paulo, Brazil, demonstrated that environmental levels ensure sufficient production of VD from unintentional sun exposure throughout the course of the year.²⁷ Thus, concerns about the use of sunscreen affecting VD levels are not justified.^27,28

In a study that specifically focused on postmenopausal women in Recife, Brazil (which is located 10º south of the equator), a considerable prevalence of VD deficiency was found, ranging from 30% to 83% depending on age. Despite the abundance of sunlight, the researchers emphasized that the VD prevalence rates found in the study were similar to those observed in nontropical countries, such as the United States and Canada; however, the period of intentional exposure to the sun was not assessed.²⁹ Moreover, the lack of consensus on the appropriate levels of sun exposure makes it difficult to compare different countries, and thus it is recommended that minimum normal limits be regionally established.^29,30

Although it has been suggested that the use of sun protection factor 15 could, in theory, promote a 99% reduction in the synthesis of VD, other studies have failed to identify such an insufficiency.^31,32 In practice, the disparity may be explained by the large variation in the amount of sunscreen applied, by the body areas to which it is applied, and by the fact that duration of sun exposure usually is greater when using sunscreen.³¹

Considering all the evidence and taking into account that the safe limit for sun exposure that allows maximum synthesis of VD without an increased risk for skin cancer remains unknown, the American Academy of Dermatology states that intentional exposure to the sun should not be considered a main source of sun exposure and the use of sunscreen should not be discouraged. Instead, the Academy recommends using dietary sources of VD or artificial VD supplementation at doses that vary by age: between 1 and 70 years, a dose of 600 IU daily is recommended; older than 70 years, 800 IU daily.³³

Primary Skin Disorders of Menopause

Pruritus

Pruritus is the primary skin concern in women older than 65 years. Given that xerosis is the most prominent cause of pruritus, consider the possible role of menopause-related transepidermal water loss.^19,34 Regardless of the underlying cause, however, some general measures are recommended for managing pruritus in menopausal women such as using low-pH moisturizers daily, preferably after bathing; keeping nails short; wearing loose and light clothing; maintaining a comfortable ambient temperature; using humidifiers or air-conditioning devices; restricting bathing time; and avoiding hot water and high-pH sanitizers.³⁴

Hyperhidrosis

Night sweats, hyperhidrosis, and hot flashes (flushing) are common concerns in 35% to 50% of perimenopausal women and in 30% to 80% of postmenopausal women.Menopausal hyperhidrosis is classified as secondary hyperhidrosis, the symptoms of which may be alleviated by HRT, suggesting that the cause is decreasing levels of estrogen.³⁵

In addition to HRT, other treatments such as gabapentin, serotonin-norepinephrine reuptake inhibitors, and acupuncture are used to treat menopausal hyperhidrosis. One study evaluated the use of oxybutynin for 3 months in 21 patients with menopausal hyperhidrosis, and the authors concluded that the drug was effective and well tolerated in women who were nonresponsive to HRT.³⁶

Senile Alopecia

Starting at 50 years of age, scalp hairs show varying degrees of change in pigmentation, growth, and diameter. Despite the normal ratio of telogen to anagen hair, there may be a considerable reduction in follicular density. The clinical distinction between senile alopecia and androgenetic alopecia can be challenging, and the conditions may coexist.²⁴

Androgenetic Alopecia

Up to 50% of women experience androgenetic alopecia, or female pattern hair loss (FPHL), during their lives.²⁴ It is the main cause of hair loss in women, and women in perimenopause are the most affected. Hair regrowth is difficult when treatment is not instituted early in perimenopausal FPHL.²⁴ The pathogenesis involves a progressive reduction in the hair cycle, resulting in shrinkage of the hair follicles.³⁷ Unlike the pathogenesis of androgenetic alopecia in men, little is known about the role of androgens in FPHL.³⁷ The measurement of androgen levels is not recommended in the absence of symptoms of virilization or in the absence of abnormal clinical patterns or progression.²⁴

Three clinical forms of FPHL have been described: (1) Ludwig classification (diffuse central thinning concentrated in the parieto-occipital region with the frontal hairline intact), (2) Olsen classification (thinning of the central line and a consequent Christmas tree pattern), and (3) Hamilton classification (frontotemporal or vertex recession, which is seen less often than the other 2 forms). Female pattern hair loss primarily is treated with a 2% to 5% minoxidil solution,³⁸ which is able to interrupt hair loss or induce mild to moderate regrowth in 60% of patients with FPHL.³⁷ The effectiveness of the treatment should only be assessed after 1 year of use.³⁷ Contact dermatitis is the main adverse effect, but its incidence may be reduced by up to 82% by using vehicles that do not contain propylene glycol.³⁹ If the use of minoxidil solution is not possible, good results also have been reported with antiandrogen medications, such as spironolactone.⁴⁰ These drugs are especially useful in cases of hyperandrogenism.³⁷

Conventional doses of finasteride 1 mg daily, as used in men, have shown discrepant results in menopausal women.^41-45 Improvement of FPHL has been shown in studies using doses of 2.5 mg or higher for a minimum of 12 months.^42-45 The use of dutasteride, an inhibitor of 5α-reductases I and II, promotes greater inhibition (100%) of dihydrotestosterone activity than finasteride (70%) in men; however, it has not yet been approved by the US Food and Drug Administration for treatment in women.⁴⁶

Impaired Wound Healing

Wound healing also is affected by aging. Delays in healing may be more closely related to the decrease in estrogen levels than to intrinsic aging. A comparison between the expression of genes associated with healing in young and elderly men showed that most of the genes are regulated exclusively by estrogen, which could explain the higher incidence of chronic ulcers in elderly men compared to women.⁴⁷ However, menopausal women also are at risk for development of chronic ulcers.⁴⁸ Ashcroft et al⁴⁹ showed that the use of topical estrogen accelerates the healing of acute incisional wounds by increasing transforming growth factor β.

Healing of the oral mucosa is associated with a higher rate of complications and longer recovery time in women than in men. Estrogens produce anti-inflammatory effects, whereas progesterone demonstrates a proinflammatory effect. Testosterone has anti-inflammatory effects and is able to modify the proinflammatory state in the oral mucosae of menopausal women. Wound healing in menopausal women who are not receiving HRT tends to be slower than in those who are receiving HRT. Age is not necessarily an important factor in wound healing. Premenopausal and younger women have shown no notable differences in healing. Nevertheless, after menopause, differences in wound healing have been found, indicating that hormonal status may be more crucial to wound healing than age.⁵⁰

Common Dermatoses With No Hormonal Associations

Brittle Nail Syndrome

Brittle nail syndrome (BNS) affects 20% of the population with a female-to-male ratio of 2:1.The pathogenesis of BNS involves factors that affect the adhesion of corneocytes to the nail plate and alter nail formation from its matrix; the former process produces onychoschizia, whereas the latter leads to onychorrhexis.⁵¹

The normal nail contains approximately 18% water, and nails with less than 16% water content are more likely to develop weakness.⁵² Nail water content appears to be negatively influenced by repetitive occupational exposure to water, and its increase is proportional to the frequency of moisturizer use. The use of certain nail polishes and cuticle removers is considered one of the main reasons for nail weakness in those who have frequent manicures.⁵³

Management of BNS requires the correction of the precipitating cause by hydration of the nail blade, cuticle, and proximal nail folds, preferably under occlusion. Supplementation with biotin is considered highly effective by many researchers.^54,55 In a retrospective study, the use of biotin for 6 months improved BNS in 63% (22/35) of patients.⁵⁶ Recommended doses generally are more than 2.5 mg daily.⁵⁷ The use of 10% urea in nail polish once or twice daily showed that both regimens improved the morphology, consistency, and reflectiveness of the nail plate.⁵²

The use of nail polish containing hydroxypropyl chitosan, Equisetum arvense extract, and methylsulfonylmethane has been reported as a treatment of dystrophic and fragile fingernails. The treatment was evaluated in patients with nail psoriasis and it was shown to be effective in decreasing dystrophy.⁵⁸

Although women are affected twice as frequently as men,⁵¹ there are no known studies comparing the prevalence of BNS in premenopausal versus menopausal women, despite the fact that the ratio of women to men affected has been shown to increase with age.^51,52 In our clinical practice, BNS predominates among menopausal women. We believe that low estrogen levels may lead to dehydration of the nail plate.

Frontal Fibrosing Alopecia

Frontal fibrosing alopecia has a tendency to affect menopausal women.⁵⁹ Frontal fibrosing alopecia is a slow, progressive, lymphocytic cicatricial alopecia that produces symmetrical frontal or temporal recession but rarely affects other areas of the scalp. It often is associated with nonscarring alopecia of body hair or eyebrows. The cicatricial area is atrophic, pale, and surrounded by hyperpigmented skin due to long-term sun damage.^60,61

Many investigators believe it is a variant of lichen planopilaris.^62,63 Others suggest the possibility that hormonal changes characteristic of perimenopause contribute to triggering the disease. Some cases show a partial response to finasteride or dutasteride.⁶⁴ Furthermore, the lymphocytic inflammatory component of the disorder has been treated with immunomodulators, topical and intralesional corticosteroids, and hydroxychloroquine.^60,63

Telogen Effluvium

Telogen effluvium (TE) is the premature transformation of hair from the anagen phase to the telogen phase. Considered a symptom of an underlying condition (eg, endocrine, nutritional, and autoimmune disorders) rather than a full diagnosis in itself,⁶⁵ TE is characterized by diffuse hair loss confirmed by a pull test in which more than 5 hairs are removed from the scalp on tugging a section of 25 to 50 hairs.⁶⁶ If there is concurrent TE in women with androgenetic alopecia, more severe hair loss has been reported.^24,66 There may be concerns of dysesthesia of the scalp (trichodynia), especially in patients with emotional stress.⁶⁶

Most often diagnosed in women, TE in its acute form is even more common in menopausal women and lasts less than 6 months.²⁴ The acute form of TE is secondary to hemorrhage, high fever, surgery, drug use, systemic diseases, diet, or great psychological stress and typically occurs 1 to 3 months after the primary event.^24,66 The most common cause of iron deficiency at menopausal transition is malabsorption or chronic gastrointestinal bleeding. Ferritin levels below 40 µg/L are associated withhair loss with a 98% specificity and sensitivity.²⁴ Low serum levels of vitamin B₁₂ or VD also are considered important factors.^24,65,66

Chronic TE (ie, lasting more than 6 months) predominantly occurs in women aged 40 to 60 years, and its onset is abrupt. Chronic TE is considered a diagnosis of exclusion.²⁴ In 30% of cases of chronic diffuse hair loss lasting longer than 6 months, the cause is unknown.⁶⁷ The pathogenesis is poorly understood, though it is assumed to result from a reduced duration of the anagen growth phase in the absence of shrinking hair follicles.^37,68

Patient education is the most important aspect of TE management. The aim of treatment is to reduce hair loss and correct the precipitating factors. Even if the underlying cause is corrected, hair loss may continue for up to 6 months with the desired cosmetic regrowth occurring after only 12 to 18 months.^37,65 In acute secondary TE, the course of the disease is self-limited, and correction of the causal factor is sufficient. In chronic diffuse loss, identification of causal factors is more difficult and treatment involves adequate nutrition (ie, at least 1200 calories daily including 9.8 mg/kg body weight of protein) and multivitamin supplementation, minoxidil, and even antiandrogen medications.^37,65-67

Trichotillomania

Trichotillomania is the compulsive behavior of plucking strands of hair and is considered to be a poor adaptive response to stress. Although trichotillomania most commonly occurs in children, adolescents, and young adults, in older adults it is more often associated with psychopathology and is markedly more common in women.⁶⁹ The condition usually is refractory to treatment, and although the scalp usually is the primary focus of the behavior, eventually patients may pluck body hair. Menopausal women also may present with trichoteiromania in which hair loss is secondary to repeated friction that has fractured the hair shaft; this condition often is associated with scalp dysesthesia.²⁴ Trichotillomania is considered an obsessive-compulsive disorder, whereas trichoteiromania needs further investigation because it can occur secondary to many psychiatric disorders. The specific psychotherapeutic and pharmacologic treatments likely will depend on the underlying cause of the disease.⁷⁰

Treatment of Skin Disorders in Menopausal Women

Classic HRT

Several studies have used histologic analysis or ultrasonography to show that estrogens used in HRT thicken the skin or increase collagen content, whether given orally, topically, or transdermally.^71-75 In a randomized, double-blind study comparing topical estrogen versus glycolic acid, 6 months of estrogen use on only one side of the face promoted a 23% increase in epidermal thickness (P=.00458), and the use of glycolic acid stimulated a 27% increase (P=.00467). The combined use of estrogen and glycolic acid prompted a 38% increase in epidermal thickness (P=.000181), with significant differences observed for all groups compared with the controls for the reversal of histologic markers of skin aging.⁷⁶

Finally, collagen synthesis also is increased as inferred by the increase in procollagen type I and II terminal peptides.⁷⁵ Hormone replacement therapy also affects the skin’s ability to retain water and leads to a reduction in skin wrinkling; however, the effects of HRT on dyschromic alterations have not been well studied.⁷⁷ The numerous adverse effects of HRT, such as an increased incidence of cancer and cardiovascular morbidity, limit its use.

Isoflavones

Estrogen use is capable of causing morphologic changes in the aged skin of menopausal women.^19,77 Given that HRT is contraindicated for some women and can cause adverse effects or pose unacceptable risks for others, Accorsi-Neto et al¹⁵ studied the possibility of achieving the beneficial effects of estrogen with plant hormones. Oral isoflavones given to rats that had been irradiated with UV light inhibited the increased expression of UV-induced metalloproteinases, reducing collagen degradation.⁷⁸

Among the phytoestrogens, genistein, an isoflavone, is notable for its selectivity, with a high affinity for estrogen receptor β and low affinity for estrogen receptor α, which is found in the uterus and breasts. Accorsi-Neto et al¹⁵ assessed whether soy isoflavones also would reduce skin aging in women, as observed in the aforementioned rat study. After 6 months of using 100 mg of concentrated soy extract daily, the investigators noted increased thickness of the dermis and epidermis, increased dermal vasculature, an increased number of collagen and elastic fibers, and an increased papillary index. In rats, genistein increases antioxidant enzymes, such as superoxide dismutase, catalase, and glutathione.^78,79 Topical phytoestrogens also were evaluated, with promising results for increased skin thickness. In animals, the use of isoflavones also offers protection against carcinogenesis in sun-damaged skin.¹⁵

Some investigators believe that a better understanding of the mechanism of action and possible side effects of phytoestrogens is essential to allow their use as a promising antiaging alternative.⁸⁰ There is no evidence that estrogens (eg, HRT) possess antioxidant or photoprotective properties.⁷⁸ Moreover, it is possible that new selective estrogen receptor modulators will specifically affect the skin without the expected systemic effects of existing estrogens.⁸⁰

Conclusion

Although often overlooked, skin disorders are quite common during menopause. Understanding the physiology of this important period in a woman’s life is essential for developing an early and effective preventive therapeutic approach. Use of sunscreens has been questioned due to a concern about osteoporosis, but studies have not shown a connection between sunscreen use and reduced VD levels. Intentional sun exposure should not be considered a source of VD; instead, recommend dietary or artificial supplementation. Although studies have shown HRT to positively affect wound healing, reduce signs of aging, increase hydration, and yield other benefits, its use is not recommended for treating skin disorders. Isoflavones could be promising alternatives to estrogen; however, further studies are needed before their use can be recommended.

ORLANDO – For patients who want to get rid of scars, consider using laser treatment for speedy and effective removal, said Dr. Joel L. Cohen, a dermatologist practicing in Englewood, Colo.

“I do spend a fair amount of my time doing [laser treatments] and I do use a lot of these laser modalities,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference. “We have them in aesthetic practices, and we have them for other things we can do, such as trying to minimize scars.”

For laser removal of a recent surgical scar, Dr. Cohen recommended the 585-nm pulsed dye laser, citing a 2010 study of 20 adults, which found that both long- and short-pulse dye lasers had no significant difference in their ability to effectively improve the appearance of surgical scars. After sutures were removed, sections of the postoperative scar of each patient were treated with the short-pulse 585-nm laser and the long-pulse 585-nm laser once a month for 3 months, and one section was left untreated to serve as controls. The investigators found that the sections treated with the laser demonstrated a statistically significant overall average improvement in appearance, as measured by the Vancouver Scar Scale, of 92% and 89%, vs. 67% for the untreated areas (Lasers Med Sci. 2010 Jan;25[1]:121-6).

For atrophic scars, fractional laser photothermolysis is considered the preferred method in a number of studies. In a 2007 study of 53 patients with mild to moderate atrophic facial acne scars, a 1,550-nm erbium-doped fiber laser was found to improve the appearance of scars safely and effectively in most of the patients (Dermatol Surg. 2007 Mar;33[3]:295-9). After three monthly treatments, almost 90% of the patients has clinical improvements averaging 51%-75%, according to the study results.

In addition, for traumatic scars, optimal treatment is via use of ablative fractional laser resurfacing, Dr. Cohen said. This approach was also mentioned in a 2014 consensus statement, which said that laser scar therapy, particularly ablative laser resurfacing, was a promising but underused tool (JAMA Dermatol. 2014;150[2]:187-93).

Importantly, Dr. Cohen advised that laser treatment can be used after traditional grafting, if surgeons and their patients are not satisfied with the aesthetic outcome of an operation.

“We don’t always get great closures,” said Dr. Cohen. “I think we’ve seen some really nice reconstructions done [but] things don’t always go great, and so this is an option” when more traditional approaches, like flaps, are simply not viable.

Preventing or minimizing scar formation

Dr. Cohen also referred to data on preventing or minimizing scar formation with approaches that include botulinum toxin.

“There are some data about using botulinum toxin to chemo-immobilize the area,” he noted, pointing to a 2006 blinded, prospective, randomized clinical trial of 31 patients, which found that botulinum toxin-induced immobilization enhanced healing of forehead wounds and improved the eventual appearance of scars (Mayo Clin Proc. 2006 Aug;81[8]:1023-8). In the study, botulinum toxin or placebo injections were administered into the muscle surrounding the wound within 24 hours after the wound was closed.

Another study, a retrospective chart review of 18 patients published in 2009, had similar results, showing that in patients who undergo facial reconstructions, botulinum toxin can help with wound healing regardless of which type (A or B) is used. When administered intraoperatively during reconstruction post Mohs micrographic surgery, botulinum toxin types A and B were effective in helping wound healing, according to the researchers (Dermatol Surg. 2009 Feb;35[2]:182-8).

Botulinum toxin type A also has been scrutinized in preclinical studies, including one that looked at its effects on the synthesis of cytokines, “in a cell culture model of cutaneous scarring.” This study found no effect of botulinum type A on cell proliferation or on cytokines and growth factors. The researchers concluded that the results did not provide evidence “to suggest a significant therapeutic role of botulinum toxin A injections for cutaneous wound healing beyond chemoimmobilization” (Arch Facial Plast Surg. 2012 Mar-Apr;14[2]:122-6).

Results of another study that looked at the effect of botulinum type A on transforming growth factor beta-1 on fibroblasts that were isolated from a hypertrophic scar suggested that it may be worth studying further as a treatment for hypertrophic scars. (Aesthetic Plast Surg. 2010 Aug;34[4]:424-7).

Dr. Cohen did not report any relevant financial disclosures.

dchitnis@frontlinemedcom.com

ORLANDO – For patients who want to get rid of scars, consider using laser treatment for speedy and effective removal, said Dr. Joel L. Cohen, a dermatologist practicing in Englewood, Colo.

“I do spend a fair amount of my time doing [laser treatments] and I do use a lot of these laser modalities,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference. “We have them in aesthetic practices, and we have them for other things we can do, such as trying to minimize scars.”

For laser removal of a recent surgical scar, Dr. Cohen recommended the 585-nm pulsed dye laser, citing a 2010 study of 20 adults, which found that both long- and short-pulse dye lasers had no significant difference in their ability to effectively improve the appearance of surgical scars. After sutures were removed, sections of the postoperative scar of each patient were treated with the short-pulse 585-nm laser and the long-pulse 585-nm laser once a month for 3 months, and one section was left untreated to serve as controls. The investigators found that the sections treated with the laser demonstrated a statistically significant overall average improvement in appearance, as measured by the Vancouver Scar Scale, of 92% and 89%, vs. 67% for the untreated areas (Lasers Med Sci. 2010 Jan;25[1]:121-6).

For atrophic scars, fractional laser photothermolysis is considered the preferred method in a number of studies. In a 2007 study of 53 patients with mild to moderate atrophic facial acne scars, a 1,550-nm erbium-doped fiber laser was found to improve the appearance of scars safely and effectively in most of the patients (Dermatol Surg. 2007 Mar;33[3]:295-9). After three monthly treatments, almost 90% of the patients has clinical improvements averaging 51%-75%, according to the study results.

In addition, for traumatic scars, optimal treatment is via use of ablative fractional laser resurfacing, Dr. Cohen said. This approach was also mentioned in a 2014 consensus statement, which said that laser scar therapy, particularly ablative laser resurfacing, was a promising but underused tool (JAMA Dermatol. 2014;150[2]:187-93).

Importantly, Dr. Cohen advised that laser treatment can be used after traditional grafting, if surgeons and their patients are not satisfied with the aesthetic outcome of an operation.

“We don’t always get great closures,” said Dr. Cohen. “I think we’ve seen some really nice reconstructions done [but] things don’t always go great, and so this is an option” when more traditional approaches, like flaps, are simply not viable.

Preventing or minimizing scar formation

Dr. Cohen also referred to data on preventing or minimizing scar formation with approaches that include botulinum toxin.

“There are some data about using botulinum toxin to chemo-immobilize the area,” he noted, pointing to a 2006 blinded, prospective, randomized clinical trial of 31 patients, which found that botulinum toxin-induced immobilization enhanced healing of forehead wounds and improved the eventual appearance of scars (Mayo Clin Proc. 2006 Aug;81[8]:1023-8). In the study, botulinum toxin or placebo injections were administered into the muscle surrounding the wound within 24 hours after the wound was closed.

Another study, a retrospective chart review of 18 patients published in 2009, had similar results, showing that in patients who undergo facial reconstructions, botulinum toxin can help with wound healing regardless of which type (A or B) is used. When administered intraoperatively during reconstruction post Mohs micrographic surgery, botulinum toxin types A and B were effective in helping wound healing, according to the researchers (Dermatol Surg. 2009 Feb;35[2]:182-8).

Botulinum toxin type A also has been scrutinized in preclinical studies, including one that looked at its effects on the synthesis of cytokines, “in a cell culture model of cutaneous scarring.” This study found no effect of botulinum type A on cell proliferation or on cytokines and growth factors. The researchers concluded that the results did not provide evidence “to suggest a significant therapeutic role of botulinum toxin A injections for cutaneous wound healing beyond chemoimmobilization” (Arch Facial Plast Surg. 2012 Mar-Apr;14[2]:122-6).

Results of another study that looked at the effect of botulinum type A on transforming growth factor beta-1 on fibroblasts that were isolated from a hypertrophic scar suggested that it may be worth studying further as a treatment for hypertrophic scars. (Aesthetic Plast Surg. 2010 Aug;34[4]:424-7).

Dr. Cohen did not report any relevant financial disclosures.

dchitnis@frontlinemedcom.com

ORLANDO – For patients who want to get rid of scars, consider using laser treatment for speedy and effective removal, said Dr. Joel L. Cohen, a dermatologist practicing in Englewood, Colo.

“I do spend a fair amount of my time doing [laser treatments] and I do use a lot of these laser modalities,” Dr. Cohen said at the Orlando Dermatology Aesthetic and Clinical Conference. “We have them in aesthetic practices, and we have them for other things we can do, such as trying to minimize scars.”

For laser removal of a recent surgical scar, Dr. Cohen recommended the 585-nm pulsed dye laser, citing a 2010 study of 20 adults, which found that both long- and short-pulse dye lasers had no significant difference in their ability to effectively improve the appearance of surgical scars. After sutures were removed, sections of the postoperative scar of each patient were treated with the short-pulse 585-nm laser and the long-pulse 585-nm laser once a month for 3 months, and one section was left untreated to serve as controls. The investigators found that the sections treated with the laser demonstrated a statistically significant overall average improvement in appearance, as measured by the Vancouver Scar Scale, of 92% and 89%, vs. 67% for the untreated areas (Lasers Med Sci. 2010 Jan;25[1]:121-6).

For atrophic scars, fractional laser photothermolysis is considered the preferred method in a number of studies. In a 2007 study of 53 patients with mild to moderate atrophic facial acne scars, a 1,550-nm erbium-doped fiber laser was found to improve the appearance of scars safely and effectively in most of the patients (Dermatol Surg. 2007 Mar;33[3]:295-9). After three monthly treatments, almost 90% of the patients has clinical improvements averaging 51%-75%, according to the study results.

In addition, for traumatic scars, optimal treatment is via use of ablative fractional laser resurfacing, Dr. Cohen said. This approach was also mentioned in a 2014 consensus statement, which said that laser scar therapy, particularly ablative laser resurfacing, was a promising but underused tool (JAMA Dermatol. 2014;150[2]:187-93).

Importantly, Dr. Cohen advised that laser treatment can be used after traditional grafting, if surgeons and their patients are not satisfied with the aesthetic outcome of an operation.

“We don’t always get great closures,” said Dr. Cohen. “I think we’ve seen some really nice reconstructions done [but] things don’t always go great, and so this is an option” when more traditional approaches, like flaps, are simply not viable.

Preventing or minimizing scar formation

Dr. Cohen also referred to data on preventing or minimizing scar formation with approaches that include botulinum toxin.

“There are some data about using botulinum toxin to chemo-immobilize the area,” he noted, pointing to a 2006 blinded, prospective, randomized clinical trial of 31 patients, which found that botulinum toxin-induced immobilization enhanced healing of forehead wounds and improved the eventual appearance of scars (Mayo Clin Proc. 2006 Aug;81[8]:1023-8). In the study, botulinum toxin or placebo injections were administered into the muscle surrounding the wound within 24 hours after the wound was closed.

Another study, a retrospective chart review of 18 patients published in 2009, had similar results, showing that in patients who undergo facial reconstructions, botulinum toxin can help with wound healing regardless of which type (A or B) is used. When administered intraoperatively during reconstruction post Mohs micrographic surgery, botulinum toxin types A and B were effective in helping wound healing, according to the researchers (Dermatol Surg. 2009 Feb;35[2]:182-8).

Botulinum toxin type A also has been scrutinized in preclinical studies, including one that looked at its effects on the synthesis of cytokines, “in a cell culture model of cutaneous scarring.” This study found no effect of botulinum type A on cell proliferation or on cytokines and growth factors. The researchers concluded that the results did not provide evidence “to suggest a significant therapeutic role of botulinum toxin A injections for cutaneous wound healing beyond chemoimmobilization” (Arch Facial Plast Surg. 2012 Mar-Apr;14[2]:122-6).

Results of another study that looked at the effect of botulinum type A on transforming growth factor beta-1 on fibroblasts that were isolated from a hypertrophic scar suggested that it may be worth studying further as a treatment for hypertrophic scars. (Aesthetic Plast Surg. 2010 Aug;34[4]:424-7).

Dr. Cohen did not report any relevant financial disclosures.

dchitnis@frontlinemedcom.com

HOLLYWOOD, FLA. – Many physicians use microfocused ultrasound (MFU-V) or other energy devices along with neurotoxins and injectable fillers, but how these therapies should be sequenced, and how closely they can be grouped, remains an open question. One physician’s look at his own and colleagues’ data found a surprising answer: it doesn’t seem to matter.

“We have had this ongoing debate for years and years on when you should use an energy device, on when you should inject a toxin, on when you should inject a filler – and maybe more importantly, on when you shouldn’t use a toxin or a filler in proximity to the energy device,” said Dr. Phillip Werschler, a cosmetic surgeon in private practice in Spokane, Wash.

There are theoretical concerns that applying heat energy to recently placed fillers or neurotoxins may alter the protein structure of the injected material, and also about injecting skin recently treated by ultrasound or other energy-based therapies, Dr. Werschler said at the annual meeting of the American Academy of Cosmetic Surgery.

Citing a paucity of evidence for best practices, Dr. Werschler and his colleagues conducted a small retrospective study – a multicenter chart review – to examine whether microfocused ultrasound (MFU-V) is safe when used within 6 months of the administration of neurotoxins and/or dermal fillers.

The study’s primary outcome measure was the incidence of adverse events in patients who were treated with both MFU-V and toxins or fillers within 6 months’ proximity. Dr. Werschler and his colleagues examined the charts of 101 patients who had received MFU-V and either a neurotoxin or a dermal filler in the previous 2 years, and for whom the injectable therapy was administered within 6 months of the energy-based treatment. “One subject did not provide gender data. 101 subjects were enrolled. 4 males, 96 females, & 1 without gender provided.”

Men and women aged 25-70 years were included in the review. Mean age was 55.3 years (range, 32-72); 4 males, and 96 females were enrolled (gender information was not provided for one patient).

All 101 patients received MFU-V treatments, with transducer depth during treatment at 1.5 mm (n = 69 treatments), 3.0 mm (n = 99), or 4.5 mm (n = 84). Some patients received treatments in more than one area, so 48 subjects received a full-face treatment, 58 received neck treatment, 45 received partial facial or other area treatment, and 7 received décolleté treatment.

Filler treatment was administered to 83 subjects, with 57 of those (69%) receiving hyaluronic acid, and 26 (31%) receiving calcium hydroxylapatite. Depth of injection varied: 59 areas had intradermal injections, 56 had subdermal injections, and 11 injections targeted the periosteal layer.

Of the 83 patients receiving fillers, 16 received MFU-V on the same treatment day, and one patient had neurotoxin.

Twenty patients received neurotoxin treatment at the muscle (48 areas) and intradermal (10 areas) layers. Of these, four also received MFU-V on the same day.

The majority of patients treated with multiple modalities received toxin or filler within 90 days before or after the MFU-V treatment (n = 48 for filler + MFU-V and n = 12 for filler + toxin).

Of the 101 enrollees, seven patients each had one adverse event. Four of these events resolved without sequelae, while the outcomes for the other three are unknown. Most of the adverse events were mild bruising, purpura, or swelling; one patient had a herpes simplex virus outbreak, one patient had paresthesias, and one patient reported moderate bruising and swelling.

“What we didn’t see is … for example, granuloma formation in those patients that were treated previously with a filler, either a particulate or a natural filler, and then heat energy was applied over it in the form of microfocused ultrasound. We didn’t see melting of the fillers.”

The retrospective chart review supports the safety of combination treatments, said Dr. Werschler. “So what does all this mean to your practice? It’s another piece of evidence – a small piece – that it’s OK to put energy over toxins and fillers,” said Dr. Werschler.

Dr. Werschler disclosed that he is a consultant, investigator and speaker for Ulthera, a division of Merz Aesthetics. He did not receive compensation for this study.

koakes@frontlinemedcom.com

On Twitter @karioakes

HOLLYWOOD, FLA. – Many physicians use microfocused ultrasound (MFU-V) or other energy devices along with neurotoxins and injectable fillers, but how these therapies should be sequenced, and how closely they can be grouped, remains an open question. One physician’s look at his own and colleagues’ data found a surprising answer: it doesn’t seem to matter.

“We have had this ongoing debate for years and years on when you should use an energy device, on when you should inject a toxin, on when you should inject a filler – and maybe more importantly, on when you shouldn’t use a toxin or a filler in proximity to the energy device,” said Dr. Phillip Werschler, a cosmetic surgeon in private practice in Spokane, Wash.

There are theoretical concerns that applying heat energy to recently placed fillers or neurotoxins may alter the protein structure of the injected material, and also about injecting skin recently treated by ultrasound or other energy-based therapies, Dr. Werschler said at the annual meeting of the American Academy of Cosmetic Surgery.

Citing a paucity of evidence for best practices, Dr. Werschler and his colleagues conducted a small retrospective study – a multicenter chart review – to examine whether microfocused ultrasound (MFU-V) is safe when used within 6 months of the administration of neurotoxins and/or dermal fillers.

The study’s primary outcome measure was the incidence of adverse events in patients who were treated with both MFU-V and toxins or fillers within 6 months’ proximity. Dr. Werschler and his colleagues examined the charts of 101 patients who had received MFU-V and either a neurotoxin or a dermal filler in the previous 2 years, and for whom the injectable therapy was administered within 6 months of the energy-based treatment. “One subject did not provide gender data. 101 subjects were enrolled. 4 males, 96 females, & 1 without gender provided.”

Men and women aged 25-70 years were included in the review. Mean age was 55.3 years (range, 32-72); 4 males, and 96 females were enrolled (gender information was not provided for one patient).

All 101 patients received MFU-V treatments, with transducer depth during treatment at 1.5 mm (n = 69 treatments), 3.0 mm (n = 99), or 4.5 mm (n = 84). Some patients received treatments in more than one area, so 48 subjects received a full-face treatment, 58 received neck treatment, 45 received partial facial or other area treatment, and 7 received décolleté treatment.

Filler treatment was administered to 83 subjects, with 57 of those (69%) receiving hyaluronic acid, and 26 (31%) receiving calcium hydroxylapatite. Depth of injection varied: 59 areas had intradermal injections, 56 had subdermal injections, and 11 injections targeted the periosteal layer.

Of the 83 patients receiving fillers, 16 received MFU-V on the same treatment day, and one patient had neurotoxin.

Twenty patients received neurotoxin treatment at the muscle (48 areas) and intradermal (10 areas) layers. Of these, four also received MFU-V on the same day.

The majority of patients treated with multiple modalities received toxin or filler within 90 days before or after the MFU-V treatment (n = 48 for filler + MFU-V and n = 12 for filler + toxin).

Of the 101 enrollees, seven patients each had one adverse event. Four of these events resolved without sequelae, while the outcomes for the other three are unknown. Most of the adverse events were mild bruising, purpura, or swelling; one patient had a herpes simplex virus outbreak, one patient had paresthesias, and one patient reported moderate bruising and swelling.

“What we didn’t see is … for example, granuloma formation in those patients that were treated previously with a filler, either a particulate or a natural filler, and then heat energy was applied over it in the form of microfocused ultrasound. We didn’t see melting of the fillers.”

The retrospective chart review supports the safety of combination treatments, said Dr. Werschler. “So what does all this mean to your practice? It’s another piece of evidence – a small piece – that it’s OK to put energy over toxins and fillers,” said Dr. Werschler.

Dr. Werschler disclosed that he is a consultant, investigator and speaker for Ulthera, a division of Merz Aesthetics. He did not receive compensation for this study.

koakes@frontlinemedcom.com

On Twitter @karioakes

HOLLYWOOD, FLA. – Many physicians use microfocused ultrasound (MFU-V) or other energy devices along with neurotoxins and injectable fillers, but how these therapies should be sequenced, and how closely they can be grouped, remains an open question. One physician’s look at his own and colleagues’ data found a surprising answer: it doesn’t seem to matter.

“We have had this ongoing debate for years and years on when you should use an energy device, on when you should inject a toxin, on when you should inject a filler – and maybe more importantly, on when you shouldn’t use a toxin or a filler in proximity to the energy device,” said Dr. Phillip Werschler, a cosmetic surgeon in private practice in Spokane, Wash.

There are theoretical concerns that applying heat energy to recently placed fillers or neurotoxins may alter the protein structure of the injected material, and also about injecting skin recently treated by ultrasound or other energy-based therapies, Dr. Werschler said at the annual meeting of the American Academy of Cosmetic Surgery.

Citing a paucity of evidence for best practices, Dr. Werschler and his colleagues conducted a small retrospective study – a multicenter chart review – to examine whether microfocused ultrasound (MFU-V) is safe when used within 6 months of the administration of neurotoxins and/or dermal fillers.

The study’s primary outcome measure was the incidence of adverse events in patients who were treated with both MFU-V and toxins or fillers within 6 months’ proximity. Dr. Werschler and his colleagues examined the charts of 101 patients who had received MFU-V and either a neurotoxin or a dermal filler in the previous 2 years, and for whom the injectable therapy was administered within 6 months of the energy-based treatment. “One subject did not provide gender data. 101 subjects were enrolled. 4 males, 96 females, & 1 without gender provided.”

Men and women aged 25-70 years were included in the review. Mean age was 55.3 years (range, 32-72); 4 males, and 96 females were enrolled (gender information was not provided for one patient).

All 101 patients received MFU-V treatments, with transducer depth during treatment at 1.5 mm (n = 69 treatments), 3.0 mm (n = 99), or 4.5 mm (n = 84). Some patients received treatments in more than one area, so 48 subjects received a full-face treatment, 58 received neck treatment, 45 received partial facial or other area treatment, and 7 received décolleté treatment.

Filler treatment was administered to 83 subjects, with 57 of those (69%) receiving hyaluronic acid, and 26 (31%) receiving calcium hydroxylapatite. Depth of injection varied: 59 areas had intradermal injections, 56 had subdermal injections, and 11 injections targeted the periosteal layer.

Of the 83 patients receiving fillers, 16 received MFU-V on the same treatment day, and one patient had neurotoxin.

Twenty patients received neurotoxin treatment at the muscle (48 areas) and intradermal (10 areas) layers. Of these, four also received MFU-V on the same day.

The majority of patients treated with multiple modalities received toxin or filler within 90 days before or after the MFU-V treatment (n = 48 for filler + MFU-V and n = 12 for filler + toxin).

Of the 101 enrollees, seven patients each had one adverse event. Four of these events resolved without sequelae, while the outcomes for the other three are unknown. Most of the adverse events were mild bruising, purpura, or swelling; one patient had a herpes simplex virus outbreak, one patient had paresthesias, and one patient reported moderate bruising and swelling.

“What we didn’t see is … for example, granuloma formation in those patients that were treated previously with a filler, either a particulate or a natural filler, and then heat energy was applied over it in the form of microfocused ultrasound. We didn’t see melting of the fillers.”

The retrospective chart review supports the safety of combination treatments, said Dr. Werschler. “So what does all this mean to your practice? It’s another piece of evidence – a small piece – that it’s OK to put energy over toxins and fillers,” said Dr. Werschler.

Dr. Werschler disclosed that he is a consultant, investigator and speaker for Ulthera, a division of Merz Aesthetics. He did not receive compensation for this study.

koakes@frontlinemedcom.com

On Twitter @karioakes