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Aesthetics in men: what dermatologists need to know
ORLANDO – The increasing frequency with which men are seeking cosmetic procedures means that dermatologists need to have a firm grasp on the important, but often overlooked differences between treating their male and female patients.
“Cosmetic procedures performed on men have increased by 273% since 1997 [and] in the last year, about 10% of all cosmetic procedures were performed on men,” Dr. Whitney Bowe said at the Orlando Dermatology Aesthetic and Clinical Conference. “We want to make sure to keep in mind that the male anatomy is very different from the female anatomy, and so you want to make sure not to feminize the male face.”
In an interview at the meeting, Dr. Terrence Keaney of George Washington University, Washington, added that it’s important to take time with your male patients to really understand what they are looking for and how to deliver the most effective treatment in the most timely manner for them.
“Men are a harder nut to crack – they’re not really sure of what procedure they want because they just don’t know about them yet, so their initial concerns are less specific,” Dr. Keaney said. “You have to tease out what men are looking for [because] they’re less likely to be forthcoming about what’s bothering them.”
The two most commonly sought procedures by male patients are neuromodulators and dermal fillers, according to Dr. Bowe, a dermatologist at Mount Sinai Hospital, New York. When it comes to the former, it’s important to remember that men have flatter, more low-set brow lines that rest along the orbital rim. While women typically prefer to have a defined arch to their brow – “like what you’d see with Megan Fox or Kim Kardashian,” Dr. Bowe clarified – this can look highly feminine in male patients, and can lead to dissatisfaction with the overall treatment results.
Furthermore, in order to achieve clinically effective results, men tend to require double the amount of neuromodulator as women. It’s important for dermatologists – and, perhaps more importantly, their staff – to not only use the appropriate amount of neuromodulator, but also discuss what the true financial costs of such procedures will be with male patients ahead of time.
“You want to make sure that you’re dosing [men] appropriately, but it’s also important to consider that when you’re discussing budget,” Dr. Bowe said. “If your staff is used to quoting a certain budget range, for men, that range might actually be doubled as compared to women.”
Men typically seek dermal filler procedures to rejuvenate the area underneath the eyes. The tear trough is a particular area of concern because of its ability to make men look perpetually tired, due to loss of soft tissue in that area – “the greatest reduction in soft tissue as compared to anywhere else on their face,” Dr. Bowe pointed out.
Procedures for the jawline are also becoming increasingly routine among men and are sought after to provide more definition, while also allowing the skin to drape onto the neck. This helps reduce the appearance of girth and mitigate physically uncomfortable situations, such as wearing a button-down shirt that becomes very tight around the neck. For both this and rejuvenation of the tear trough, Dr. Bowe recommends hyaluronic acid fillers that have a high G prime, or poly-L-lactic acid (PLLA).
The other methods for dealing with submental fat in men are deoxycholic acid (Kybella), approved as a treatment for adults with moderate to severe submental fat in 2015; and cryolipolysis. With deoxycholic acid, Dr. Bowe explained, dermatologists can customize the approach because it is administered in a syringe, “something we’re very comfortable doing in our field.” However, the major drawbacks are that it’s difficult to address the lateral deposits of fat when getting close to the marginal mandibular nerve, along with significant swelling that occurs after that procedure for up to 2 weeks.
With cryolipolysis, new applicators on the market have proven effective for treating both submental fat and the lateral fat with minimal postprocedure downtime. However, applicators tend to be “one size fits all,” so if it doesn’t work for a patient, the procedure would have to be done with deoxycholic acid.
A consideration when treating male patients with fillers is that the cheek is more flat in men, who tend to have a flatter ogee curve, so an “upsweeping cheekbone [is] a feminizing look to a male patient” that dermatologists should be keen to avoid, Dr. Bowe said.
In addition, “men tend to have a higher degree of vasculature underneath the skin surface – in fact, Doppler studies show that they tend to have more vessels in their skin – and it’s most likely a result of the fact that they have increased numbers of coarse terminal hairs [which] need to sustain that growth,” cautioned Dr. Bowe. “But that also clinically translates into the fact that they’re much more prone to bruising, so that’s something you need to be very upfront with your male patients prior to engaging in any kind of injectables.”
While less common, noninvasive body contouring is something men often look for, too. Cryolipolysis can also be used for contouring, said Dr. Keaney, while Dr. Bowe advises keeping the golden ratio of shoulder-to-waist size in mind when consulting male patients about ways to improve their physique.
“There’s the ‘Adonis Ratio’ in which a man’s shoulder circumference is 1.68 times the size of his waist, and if you achieve that ratio it’s considered the ideal male physique,” Dr. Bowe explained. “By targeting the muffin top and the love handles [to] minimize the waist circumference, we can get patients closer to that ideal aesthetic.”
Dr. Keaney, who is also with the Washington Institute of Dermatologic Laser Surgery, added that in a not-yet-published study that he conducted, which surveyed 600 men about their most prominent aging concerns, hair loss was No. 1 “by far.” Dermatologists should know ahead of time that alopecia will be a frequent topic of discussion with men, far more so than with female patients, he pointed out.
Dr. Bowe disclosed consultancy relationships with Allergan and Galderma. Dr. Keaney disclosed relationships with Allergan, Restoration Robotics, and Skinceuticals.
ORLANDO – The increasing frequency with which men are seeking cosmetic procedures means that dermatologists need to have a firm grasp on the important, but often overlooked differences between treating their male and female patients.
“Cosmetic procedures performed on men have increased by 273% since 1997 [and] in the last year, about 10% of all cosmetic procedures were performed on men,” Dr. Whitney Bowe said at the Orlando Dermatology Aesthetic and Clinical Conference. “We want to make sure to keep in mind that the male anatomy is very different from the female anatomy, and so you want to make sure not to feminize the male face.”
In an interview at the meeting, Dr. Terrence Keaney of George Washington University, Washington, added that it’s important to take time with your male patients to really understand what they are looking for and how to deliver the most effective treatment in the most timely manner for them.
“Men are a harder nut to crack – they’re not really sure of what procedure they want because they just don’t know about them yet, so their initial concerns are less specific,” Dr. Keaney said. “You have to tease out what men are looking for [because] they’re less likely to be forthcoming about what’s bothering them.”
The two most commonly sought procedures by male patients are neuromodulators and dermal fillers, according to Dr. Bowe, a dermatologist at Mount Sinai Hospital, New York. When it comes to the former, it’s important to remember that men have flatter, more low-set brow lines that rest along the orbital rim. While women typically prefer to have a defined arch to their brow – “like what you’d see with Megan Fox or Kim Kardashian,” Dr. Bowe clarified – this can look highly feminine in male patients, and can lead to dissatisfaction with the overall treatment results.
Furthermore, in order to achieve clinically effective results, men tend to require double the amount of neuromodulator as women. It’s important for dermatologists – and, perhaps more importantly, their staff – to not only use the appropriate amount of neuromodulator, but also discuss what the true financial costs of such procedures will be with male patients ahead of time.
“You want to make sure that you’re dosing [men] appropriately, but it’s also important to consider that when you’re discussing budget,” Dr. Bowe said. “If your staff is used to quoting a certain budget range, for men, that range might actually be doubled as compared to women.”
Men typically seek dermal filler procedures to rejuvenate the area underneath the eyes. The tear trough is a particular area of concern because of its ability to make men look perpetually tired, due to loss of soft tissue in that area – “the greatest reduction in soft tissue as compared to anywhere else on their face,” Dr. Bowe pointed out.
Procedures for the jawline are also becoming increasingly routine among men and are sought after to provide more definition, while also allowing the skin to drape onto the neck. This helps reduce the appearance of girth and mitigate physically uncomfortable situations, such as wearing a button-down shirt that becomes very tight around the neck. For both this and rejuvenation of the tear trough, Dr. Bowe recommends hyaluronic acid fillers that have a high G prime, or poly-L-lactic acid (PLLA).
The other methods for dealing with submental fat in men are deoxycholic acid (Kybella), approved as a treatment for adults with moderate to severe submental fat in 2015; and cryolipolysis. With deoxycholic acid, Dr. Bowe explained, dermatologists can customize the approach because it is administered in a syringe, “something we’re very comfortable doing in our field.” However, the major drawbacks are that it’s difficult to address the lateral deposits of fat when getting close to the marginal mandibular nerve, along with significant swelling that occurs after that procedure for up to 2 weeks.
With cryolipolysis, new applicators on the market have proven effective for treating both submental fat and the lateral fat with minimal postprocedure downtime. However, applicators tend to be “one size fits all,” so if it doesn’t work for a patient, the procedure would have to be done with deoxycholic acid.
A consideration when treating male patients with fillers is that the cheek is more flat in men, who tend to have a flatter ogee curve, so an “upsweeping cheekbone [is] a feminizing look to a male patient” that dermatologists should be keen to avoid, Dr. Bowe said.
In addition, “men tend to have a higher degree of vasculature underneath the skin surface – in fact, Doppler studies show that they tend to have more vessels in their skin – and it’s most likely a result of the fact that they have increased numbers of coarse terminal hairs [which] need to sustain that growth,” cautioned Dr. Bowe. “But that also clinically translates into the fact that they’re much more prone to bruising, so that’s something you need to be very upfront with your male patients prior to engaging in any kind of injectables.”
While less common, noninvasive body contouring is something men often look for, too. Cryolipolysis can also be used for contouring, said Dr. Keaney, while Dr. Bowe advises keeping the golden ratio of shoulder-to-waist size in mind when consulting male patients about ways to improve their physique.
“There’s the ‘Adonis Ratio’ in which a man’s shoulder circumference is 1.68 times the size of his waist, and if you achieve that ratio it’s considered the ideal male physique,” Dr. Bowe explained. “By targeting the muffin top and the love handles [to] minimize the waist circumference, we can get patients closer to that ideal aesthetic.”
Dr. Keaney, who is also with the Washington Institute of Dermatologic Laser Surgery, added that in a not-yet-published study that he conducted, which surveyed 600 men about their most prominent aging concerns, hair loss was No. 1 “by far.” Dermatologists should know ahead of time that alopecia will be a frequent topic of discussion with men, far more so than with female patients, he pointed out.
Dr. Bowe disclosed consultancy relationships with Allergan and Galderma. Dr. Keaney disclosed relationships with Allergan, Restoration Robotics, and Skinceuticals.
ORLANDO – The increasing frequency with which men are seeking cosmetic procedures means that dermatologists need to have a firm grasp on the important, but often overlooked differences between treating their male and female patients.
“Cosmetic procedures performed on men have increased by 273% since 1997 [and] in the last year, about 10% of all cosmetic procedures were performed on men,” Dr. Whitney Bowe said at the Orlando Dermatology Aesthetic and Clinical Conference. “We want to make sure to keep in mind that the male anatomy is very different from the female anatomy, and so you want to make sure not to feminize the male face.”
In an interview at the meeting, Dr. Terrence Keaney of George Washington University, Washington, added that it’s important to take time with your male patients to really understand what they are looking for and how to deliver the most effective treatment in the most timely manner for them.
“Men are a harder nut to crack – they’re not really sure of what procedure they want because they just don’t know about them yet, so their initial concerns are less specific,” Dr. Keaney said. “You have to tease out what men are looking for [because] they’re less likely to be forthcoming about what’s bothering them.”
The two most commonly sought procedures by male patients are neuromodulators and dermal fillers, according to Dr. Bowe, a dermatologist at Mount Sinai Hospital, New York. When it comes to the former, it’s important to remember that men have flatter, more low-set brow lines that rest along the orbital rim. While women typically prefer to have a defined arch to their brow – “like what you’d see with Megan Fox or Kim Kardashian,” Dr. Bowe clarified – this can look highly feminine in male patients, and can lead to dissatisfaction with the overall treatment results.
Furthermore, in order to achieve clinically effective results, men tend to require double the amount of neuromodulator as women. It’s important for dermatologists – and, perhaps more importantly, their staff – to not only use the appropriate amount of neuromodulator, but also discuss what the true financial costs of such procedures will be with male patients ahead of time.
“You want to make sure that you’re dosing [men] appropriately, but it’s also important to consider that when you’re discussing budget,” Dr. Bowe said. “If your staff is used to quoting a certain budget range, for men, that range might actually be doubled as compared to women.”
Men typically seek dermal filler procedures to rejuvenate the area underneath the eyes. The tear trough is a particular area of concern because of its ability to make men look perpetually tired, due to loss of soft tissue in that area – “the greatest reduction in soft tissue as compared to anywhere else on their face,” Dr. Bowe pointed out.
Procedures for the jawline are also becoming increasingly routine among men and are sought after to provide more definition, while also allowing the skin to drape onto the neck. This helps reduce the appearance of girth and mitigate physically uncomfortable situations, such as wearing a button-down shirt that becomes very tight around the neck. For both this and rejuvenation of the tear trough, Dr. Bowe recommends hyaluronic acid fillers that have a high G prime, or poly-L-lactic acid (PLLA).
The other methods for dealing with submental fat in men are deoxycholic acid (Kybella), approved as a treatment for adults with moderate to severe submental fat in 2015; and cryolipolysis. With deoxycholic acid, Dr. Bowe explained, dermatologists can customize the approach because it is administered in a syringe, “something we’re very comfortable doing in our field.” However, the major drawbacks are that it’s difficult to address the lateral deposits of fat when getting close to the marginal mandibular nerve, along with significant swelling that occurs after that procedure for up to 2 weeks.
With cryolipolysis, new applicators on the market have proven effective for treating both submental fat and the lateral fat with minimal postprocedure downtime. However, applicators tend to be “one size fits all,” so if it doesn’t work for a patient, the procedure would have to be done with deoxycholic acid.
A consideration when treating male patients with fillers is that the cheek is more flat in men, who tend to have a flatter ogee curve, so an “upsweeping cheekbone [is] a feminizing look to a male patient” that dermatologists should be keen to avoid, Dr. Bowe said.
In addition, “men tend to have a higher degree of vasculature underneath the skin surface – in fact, Doppler studies show that they tend to have more vessels in their skin – and it’s most likely a result of the fact that they have increased numbers of coarse terminal hairs [which] need to sustain that growth,” cautioned Dr. Bowe. “But that also clinically translates into the fact that they’re much more prone to bruising, so that’s something you need to be very upfront with your male patients prior to engaging in any kind of injectables.”
While less common, noninvasive body contouring is something men often look for, too. Cryolipolysis can also be used for contouring, said Dr. Keaney, while Dr. Bowe advises keeping the golden ratio of shoulder-to-waist size in mind when consulting male patients about ways to improve their physique.
“There’s the ‘Adonis Ratio’ in which a man’s shoulder circumference is 1.68 times the size of his waist, and if you achieve that ratio it’s considered the ideal male physique,” Dr. Bowe explained. “By targeting the muffin top and the love handles [to] minimize the waist circumference, we can get patients closer to that ideal aesthetic.”
Dr. Keaney, who is also with the Washington Institute of Dermatologic Laser Surgery, added that in a not-yet-published study that he conducted, which surveyed 600 men about their most prominent aging concerns, hair loss was No. 1 “by far.” Dermatologists should know ahead of time that alopecia will be a frequent topic of discussion with men, far more so than with female patients, he pointed out.
Dr. Bowe disclosed consultancy relationships with Allergan and Galderma. Dr. Keaney disclosed relationships with Allergan, Restoration Robotics, and Skinceuticals.
EXPERT ANALYSIS FROM THE ODAC CONFERENCE
Clinical experience fine-tunes tips, tricks for deoxycholic acid
HOLLYWOOD, FL. – Pick the right patient, set realistic expectations, and use a cautious technique for the best result with deoxycholic acid, advised Joe Niamtu, DMD, a cosmetic facial surgeon in private practice in Midlothian, Va.
Speaking at the annual meeting of the American Academy of Cosmetic Surgery, Dr. Niamtu shared tips and techniques for best results using deoxycholic acid (Kybella) injection for reduction of submental fat, based on several months of real world use since it was approved in 2015.
Deoxycholic acid, a bile acid, causes breakdown of adipocytes when injected into fatty tissue. Since the resulting dissolution of fat cells is permanent, once the desired aesthetic effect is achieved, retreatment should not be needed, he said.
Currently, deoxycholic acid injection is only approved for the treatment of submental fat. Dr. Niamtu reviewed results of the pivotal phase III clinical trials for this indication, which characterized 68.2% of those receiving deoxycholic acid as treatment responders, compared with 20.5% of patients receiving placebo injections. Response was assessed by validated physician and patient assessment measures.
In clinical trials, the most common side effects were edema, hematoma, and pain, as well as numbness, erythema, and induration.
Whether it makes sense for an individual practice to offer deoxycholic acid injections “depends on the flavor of your practice,” Dr. Niamtu said. “I have a surgical practice, and my patients expect a big bang,” so only a limited number of his patients would be attracted to this procedure. By contrast, in a minimally invasive practice, this procedure might be more popular.
Overall, deoxycholic acid is an attractive option for patients who wish to avoid surgical procedures but still are seeking modest improvement in submental fat, he said. “It all depends what kind of practice you have, what kind of patients you attract, what their expectations are.”
The components of a youthful and fit-appearing neckline include a distinct mandibular border and subhyoid depression, a visible thyroid cartilage bulge, a visible anterior sternocleidomastoid line, and the cervicomental angle.
“There’s one thing about youth, and it’s that nice, defined cervicomental angle,” said Dr. Niamtu. “It’s important to understand what a youthful neck is, because that’s your endpoint.” When a double chin” appears, that angle droops and a crisp profile is lost.
Appropriate candidates for deoxycholic injection are “young people that have isolated fat deposits without skin excess,” said Dr. Niamtu. “If you inject Kybella into somebody who has a lot of extra skin, and they get a bad result, this stuff can come back to haunt you,” he said, recommending not to “sugar-coat predicted results and recovery.”
“When you are dealing with fat…there are some things you have to monitor,” he pointed out. He recommended taking very careful before and after pictures, and also weighing patients and calculating body mass index at each session. He also recommended taking pictures while the patient is smiling and puckering, to identify any preexisting paresis or asymmetry.
When injecting deoxycholic acid, the target is the preplatysmal fat of the submental triangle. “You’ve got to know where to put this stuff. The marginal mandibular nerve is vulnerable,” Dr. Niamtu observed. It can be tempting to treat the jowl, he said, but it’s important to give the nerve a wide margin, especially at a point about 2 cm lateral to the oral commissure, because that’s where the marginal mandibular nerve’s course becomes quite superficial.
“When you’re anterior to the mandibular notch, that nerve runs close to the mandibular border,” he said, noting that a number of mandibular nerve palsies were caused during the trials of deoxycholic acid. The resulting paresis gives an asymmetric smile, with less depression of the lower lip on the affected side since the depressor anguli oris and depressor labii are affected. In clinical trials, all episodes of paresis resolved spontaneously after a mean of 44 days.
To identify the targeted fat tissue, the operator can pinch the submental fat, or have the patient clench his or her teeth or tense the platysma. Though some apply topical anesthesia before deoxycholic acid injection, Dr. Niamtu, who uses a 32 gauge needle, does not. He prefers to use 2% lidocaine with epinephrine once the deoxycholic acid is going in and starts to burn, in order to avoid obscuring the fat target while planning the injection, and also to minimize any possibility of diluting the deoxycholic acid.
The product comes a wettable template that transfers a temporary tattoo of injection sites to the submental triangle, with 1 cm spacing between the dots to indicate where to inject. Each site receives 0.2 mL of deoxycholic acid. The mandibular border is marked, and another line is drawn about a finger breadth below the mandibular border. This second line forms the outer bound of the injection area. “That’s our no-fly zone. We don’t want to inject there. That’s where the marginal mandibular nerve lives,” said Dr. Niamtu.
He uses about 4-6 mL of deoxycholic acid per patient session. In treatment planning, the dose can be calculated once the tattoo is applied, multiplying the number of dots within the treatment zone by 0.2 mL per site. It’s important to remember to stay superficial when injecting, a technique that’s different than that used in many other injectables, Dr. Niamtu said.
Patients experience swelling, so they should be prepared for significant edema and submental fullness and some discomfort, bruising, and numbness in the few days after the procedure. However, Dr. Niamtu said all of his patients have been able to return to work the next day.
In clinical trials, most patients received two to four treatment sessions, which can get expensive for the patient, he said. “I could do a facelift for what it’s going to cost sometimes.”
Dr. Niamtu is a trainer for Allergan, the manufacturer of Kybella.
On Twitter @karioakes
HOLLYWOOD, FL. – Pick the right patient, set realistic expectations, and use a cautious technique for the best result with deoxycholic acid, advised Joe Niamtu, DMD, a cosmetic facial surgeon in private practice in Midlothian, Va.
Speaking at the annual meeting of the American Academy of Cosmetic Surgery, Dr. Niamtu shared tips and techniques for best results using deoxycholic acid (Kybella) injection for reduction of submental fat, based on several months of real world use since it was approved in 2015.
Deoxycholic acid, a bile acid, causes breakdown of adipocytes when injected into fatty tissue. Since the resulting dissolution of fat cells is permanent, once the desired aesthetic effect is achieved, retreatment should not be needed, he said.
Currently, deoxycholic acid injection is only approved for the treatment of submental fat. Dr. Niamtu reviewed results of the pivotal phase III clinical trials for this indication, which characterized 68.2% of those receiving deoxycholic acid as treatment responders, compared with 20.5% of patients receiving placebo injections. Response was assessed by validated physician and patient assessment measures.
In clinical trials, the most common side effects were edema, hematoma, and pain, as well as numbness, erythema, and induration.
Whether it makes sense for an individual practice to offer deoxycholic acid injections “depends on the flavor of your practice,” Dr. Niamtu said. “I have a surgical practice, and my patients expect a big bang,” so only a limited number of his patients would be attracted to this procedure. By contrast, in a minimally invasive practice, this procedure might be more popular.
Overall, deoxycholic acid is an attractive option for patients who wish to avoid surgical procedures but still are seeking modest improvement in submental fat, he said. “It all depends what kind of practice you have, what kind of patients you attract, what their expectations are.”
The components of a youthful and fit-appearing neckline include a distinct mandibular border and subhyoid depression, a visible thyroid cartilage bulge, a visible anterior sternocleidomastoid line, and the cervicomental angle.
“There’s one thing about youth, and it’s that nice, defined cervicomental angle,” said Dr. Niamtu. “It’s important to understand what a youthful neck is, because that’s your endpoint.” When a double chin” appears, that angle droops and a crisp profile is lost.
Appropriate candidates for deoxycholic injection are “young people that have isolated fat deposits without skin excess,” said Dr. Niamtu. “If you inject Kybella into somebody who has a lot of extra skin, and they get a bad result, this stuff can come back to haunt you,” he said, recommending not to “sugar-coat predicted results and recovery.”
“When you are dealing with fat…there are some things you have to monitor,” he pointed out. He recommended taking very careful before and after pictures, and also weighing patients and calculating body mass index at each session. He also recommended taking pictures while the patient is smiling and puckering, to identify any preexisting paresis or asymmetry.
When injecting deoxycholic acid, the target is the preplatysmal fat of the submental triangle. “You’ve got to know where to put this stuff. The marginal mandibular nerve is vulnerable,” Dr. Niamtu observed. It can be tempting to treat the jowl, he said, but it’s important to give the nerve a wide margin, especially at a point about 2 cm lateral to the oral commissure, because that’s where the marginal mandibular nerve’s course becomes quite superficial.
“When you’re anterior to the mandibular notch, that nerve runs close to the mandibular border,” he said, noting that a number of mandibular nerve palsies were caused during the trials of deoxycholic acid. The resulting paresis gives an asymmetric smile, with less depression of the lower lip on the affected side since the depressor anguli oris and depressor labii are affected. In clinical trials, all episodes of paresis resolved spontaneously after a mean of 44 days.
To identify the targeted fat tissue, the operator can pinch the submental fat, or have the patient clench his or her teeth or tense the platysma. Though some apply topical anesthesia before deoxycholic acid injection, Dr. Niamtu, who uses a 32 gauge needle, does not. He prefers to use 2% lidocaine with epinephrine once the deoxycholic acid is going in and starts to burn, in order to avoid obscuring the fat target while planning the injection, and also to minimize any possibility of diluting the deoxycholic acid.
The product comes a wettable template that transfers a temporary tattoo of injection sites to the submental triangle, with 1 cm spacing between the dots to indicate where to inject. Each site receives 0.2 mL of deoxycholic acid. The mandibular border is marked, and another line is drawn about a finger breadth below the mandibular border. This second line forms the outer bound of the injection area. “That’s our no-fly zone. We don’t want to inject there. That’s where the marginal mandibular nerve lives,” said Dr. Niamtu.
He uses about 4-6 mL of deoxycholic acid per patient session. In treatment planning, the dose can be calculated once the tattoo is applied, multiplying the number of dots within the treatment zone by 0.2 mL per site. It’s important to remember to stay superficial when injecting, a technique that’s different than that used in many other injectables, Dr. Niamtu said.
Patients experience swelling, so they should be prepared for significant edema and submental fullness and some discomfort, bruising, and numbness in the few days after the procedure. However, Dr. Niamtu said all of his patients have been able to return to work the next day.
In clinical trials, most patients received two to four treatment sessions, which can get expensive for the patient, he said. “I could do a facelift for what it’s going to cost sometimes.”
Dr. Niamtu is a trainer for Allergan, the manufacturer of Kybella.
On Twitter @karioakes
HOLLYWOOD, FL. – Pick the right patient, set realistic expectations, and use a cautious technique for the best result with deoxycholic acid, advised Joe Niamtu, DMD, a cosmetic facial surgeon in private practice in Midlothian, Va.
Speaking at the annual meeting of the American Academy of Cosmetic Surgery, Dr. Niamtu shared tips and techniques for best results using deoxycholic acid (Kybella) injection for reduction of submental fat, based on several months of real world use since it was approved in 2015.
Deoxycholic acid, a bile acid, causes breakdown of adipocytes when injected into fatty tissue. Since the resulting dissolution of fat cells is permanent, once the desired aesthetic effect is achieved, retreatment should not be needed, he said.
Currently, deoxycholic acid injection is only approved for the treatment of submental fat. Dr. Niamtu reviewed results of the pivotal phase III clinical trials for this indication, which characterized 68.2% of those receiving deoxycholic acid as treatment responders, compared with 20.5% of patients receiving placebo injections. Response was assessed by validated physician and patient assessment measures.
In clinical trials, the most common side effects were edema, hematoma, and pain, as well as numbness, erythema, and induration.
Whether it makes sense for an individual practice to offer deoxycholic acid injections “depends on the flavor of your practice,” Dr. Niamtu said. “I have a surgical practice, and my patients expect a big bang,” so only a limited number of his patients would be attracted to this procedure. By contrast, in a minimally invasive practice, this procedure might be more popular.
Overall, deoxycholic acid is an attractive option for patients who wish to avoid surgical procedures but still are seeking modest improvement in submental fat, he said. “It all depends what kind of practice you have, what kind of patients you attract, what their expectations are.”
The components of a youthful and fit-appearing neckline include a distinct mandibular border and subhyoid depression, a visible thyroid cartilage bulge, a visible anterior sternocleidomastoid line, and the cervicomental angle.
“There’s one thing about youth, and it’s that nice, defined cervicomental angle,” said Dr. Niamtu. “It’s important to understand what a youthful neck is, because that’s your endpoint.” When a double chin” appears, that angle droops and a crisp profile is lost.
Appropriate candidates for deoxycholic injection are “young people that have isolated fat deposits without skin excess,” said Dr. Niamtu. “If you inject Kybella into somebody who has a lot of extra skin, and they get a bad result, this stuff can come back to haunt you,” he said, recommending not to “sugar-coat predicted results and recovery.”
“When you are dealing with fat…there are some things you have to monitor,” he pointed out. He recommended taking very careful before and after pictures, and also weighing patients and calculating body mass index at each session. He also recommended taking pictures while the patient is smiling and puckering, to identify any preexisting paresis or asymmetry.
When injecting deoxycholic acid, the target is the preplatysmal fat of the submental triangle. “You’ve got to know where to put this stuff. The marginal mandibular nerve is vulnerable,” Dr. Niamtu observed. It can be tempting to treat the jowl, he said, but it’s important to give the nerve a wide margin, especially at a point about 2 cm lateral to the oral commissure, because that’s where the marginal mandibular nerve’s course becomes quite superficial.
“When you’re anterior to the mandibular notch, that nerve runs close to the mandibular border,” he said, noting that a number of mandibular nerve palsies were caused during the trials of deoxycholic acid. The resulting paresis gives an asymmetric smile, with less depression of the lower lip on the affected side since the depressor anguli oris and depressor labii are affected. In clinical trials, all episodes of paresis resolved spontaneously after a mean of 44 days.
To identify the targeted fat tissue, the operator can pinch the submental fat, or have the patient clench his or her teeth or tense the platysma. Though some apply topical anesthesia before deoxycholic acid injection, Dr. Niamtu, who uses a 32 gauge needle, does not. He prefers to use 2% lidocaine with epinephrine once the deoxycholic acid is going in and starts to burn, in order to avoid obscuring the fat target while planning the injection, and also to minimize any possibility of diluting the deoxycholic acid.
The product comes a wettable template that transfers a temporary tattoo of injection sites to the submental triangle, with 1 cm spacing between the dots to indicate where to inject. Each site receives 0.2 mL of deoxycholic acid. The mandibular border is marked, and another line is drawn about a finger breadth below the mandibular border. This second line forms the outer bound of the injection area. “That’s our no-fly zone. We don’t want to inject there. That’s where the marginal mandibular nerve lives,” said Dr. Niamtu.
He uses about 4-6 mL of deoxycholic acid per patient session. In treatment planning, the dose can be calculated once the tattoo is applied, multiplying the number of dots within the treatment zone by 0.2 mL per site. It’s important to remember to stay superficial when injecting, a technique that’s different than that used in many other injectables, Dr. Niamtu said.
Patients experience swelling, so they should be prepared for significant edema and submental fullness and some discomfort, bruising, and numbness in the few days after the procedure. However, Dr. Niamtu said all of his patients have been able to return to work the next day.
In clinical trials, most patients received two to four treatment sessions, which can get expensive for the patient, he said. “I could do a facelift for what it’s going to cost sometimes.”
Dr. Niamtu is a trainer for Allergan, the manufacturer of Kybella.
On Twitter @karioakes
EXPERT ANALYSIS FROM THE AACS ANNUAL MEETING
Cosmeceuticals and rosacea: which ones are worth your time
ORLANDO – When treating rosacea, consider adding cosmeceuticals to more conventional prescriptions and over-the-counter treatments to improve the management of symptoms and patient satisfaction.
The recommendation comes from Dr. Julie Harper, a dermatologist at the University of Alabama-Birmingham, who spoke about the benefits of cosmeceuticals for rosacea at the Orlando Dermatology Aesthetic and Clinical Conference.
“I see about 40 people a day on my regular dermatology days [and] it’s easy to just write a prescription and hand it to that rosacea patient, but you do them a big disservice when you do that,” explained Dr. Harper. “We’ve got to talk about triggers, about skin care, about sun protection, [and] start that discussion from there.”
The most-important point for patients to understand is the main triggers of their rosacea, which can include ultraviolet light, spices, stress, exercise, heat, barrier disruption, and Demodex. Since sunlight is the No. 1 trigger for rosacea, treatment strategies often need to start there and revolve around how to avoid or manage the condition based on sun exposure.
As for cosmeceuticals, Dr. Harper focused on three types that have been shown to be effective against rosacea: niacinamide, licorice, and green tea.
The available data on niacinamide for rosacea are primarily from the 2006 Nicomide Improvement in Clinical Outcomes Study (NICOS), an open-label, multicenter, prospective cohort study that recruited people with acne vulgaris and acne rosacea from 100 centers and administered 750 mg of niacinamide with zinc and copper, while some got niacinamide plus oral antibiotics. The 49 people with rosacea who were enrolled received baseline assessments in the clinic, but 4-week and 8-week follow-ups were done via self-reported surveys (Cutis. 2006 Jan;77[1 Suppl]:17-28).
At 8 weeks, “75% of the rosacea group reported that appearance of their rosacea was moderately or much better [and] that there was also significant reduction in inflammatory lesions,” Dr. Harper said. “There was not a big difference in the group that had an oral antibiotic and niacinamide, versus niacinamide without the oral antibiotic,” although the design of the study leaves the findings somewhat questionable, she noted.
Topical niacinamide also has the potential to benefit certain rosacea patients, she said, referring to a 2005 study examining the effects of a niacinamide-containing moisturizer on the face and one forearm of 50 patients over 4 weeks. The primary outcome of the trial was barrier function, as measured by a dimethyl sulfoxide (DMSO) chemical probe (Cutis. 2005 Aug;76[2]:135-41).
While the results of this trial are “difficult” to interpret – due largely to the lack of any real measurement of facial improvement in barrier function and the confusion over whether any improvement on the forearm can be attributed to the niacinamide specifically or to the moisturizer itself – “long story short, niacinamide did seem to help the barrier function in this particular study,” Dr. Harper said. The takeaway, therefore, is that topical niacinamide treatments may offer some value to certain patients.
Moving on to licorice, Dr. Harper discussed an open label study recently published online in the Journal of the European Academy of Dermatology and Venereology, in which subjects were given a complete skin care system – which contained a cleanser, a day cream, a night cream, and a concealer product containing licochalcone A (licorice extract). They were evaluated over a period of 8 weeks for improvement in erythema, burning, stinging, tingling, and tightness, all of which were measured at baseline (J Eur Acad Dermatol Venereol. 2016 Feb;30 Suppl 1:21-7).
Results showed “improvement of statistical significance,” Dr. Harper said. “All groups had improvement over time, and did better at 8 weeks than at 4 weeks [although] the rosacea group did not reach statistical significance until week 8.”
Finally, with green tea, Dr. Harper pointed to a 2010 randomized double-blind split-face study of just four healthy individuals with erythema and telangiectasia of the face, treated for 6 weeks with a cream containing epigallocatechin-3-gallate (EGCG), the major catechin found in green tea, on one side of their face; a vehicle cream was applied to the other side and punch biopsies were performed to determine improvements (Int J Clin Exp Pathol. 2010;3[7]:705-9). EGCG cream was used because of its “antioxidant, immunomodulatory, photoprotective, antiangiogenic – that’s the standout here, that’s what we really need – and anti-inflammatory properties,” Dr. Harper said.
While biopsies did not reveal any changes to facial vasculature, there “was a significant reduction in hypoxia-inducible factor-1 and VEGF [vascular endothelial growth factor],” which are both markers of angiogenesis – indicating some degree of usefulness against rosacea, Dr. Harper said. However, a longer, more definitive study would be needed to substantiate these findings, she added.
Dr. Harper did not report any relevant financial disclosures.
ORLANDO – When treating rosacea, consider adding cosmeceuticals to more conventional prescriptions and over-the-counter treatments to improve the management of symptoms and patient satisfaction.
The recommendation comes from Dr. Julie Harper, a dermatologist at the University of Alabama-Birmingham, who spoke about the benefits of cosmeceuticals for rosacea at the Orlando Dermatology Aesthetic and Clinical Conference.
“I see about 40 people a day on my regular dermatology days [and] it’s easy to just write a prescription and hand it to that rosacea patient, but you do them a big disservice when you do that,” explained Dr. Harper. “We’ve got to talk about triggers, about skin care, about sun protection, [and] start that discussion from there.”
The most-important point for patients to understand is the main triggers of their rosacea, which can include ultraviolet light, spices, stress, exercise, heat, barrier disruption, and Demodex. Since sunlight is the No. 1 trigger for rosacea, treatment strategies often need to start there and revolve around how to avoid or manage the condition based on sun exposure.
As for cosmeceuticals, Dr. Harper focused on three types that have been shown to be effective against rosacea: niacinamide, licorice, and green tea.
The available data on niacinamide for rosacea are primarily from the 2006 Nicomide Improvement in Clinical Outcomes Study (NICOS), an open-label, multicenter, prospective cohort study that recruited people with acne vulgaris and acne rosacea from 100 centers and administered 750 mg of niacinamide with zinc and copper, while some got niacinamide plus oral antibiotics. The 49 people with rosacea who were enrolled received baseline assessments in the clinic, but 4-week and 8-week follow-ups were done via self-reported surveys (Cutis. 2006 Jan;77[1 Suppl]:17-28).
At 8 weeks, “75% of the rosacea group reported that appearance of their rosacea was moderately or much better [and] that there was also significant reduction in inflammatory lesions,” Dr. Harper said. “There was not a big difference in the group that had an oral antibiotic and niacinamide, versus niacinamide without the oral antibiotic,” although the design of the study leaves the findings somewhat questionable, she noted.
Topical niacinamide also has the potential to benefit certain rosacea patients, she said, referring to a 2005 study examining the effects of a niacinamide-containing moisturizer on the face and one forearm of 50 patients over 4 weeks. The primary outcome of the trial was barrier function, as measured by a dimethyl sulfoxide (DMSO) chemical probe (Cutis. 2005 Aug;76[2]:135-41).
While the results of this trial are “difficult” to interpret – due largely to the lack of any real measurement of facial improvement in barrier function and the confusion over whether any improvement on the forearm can be attributed to the niacinamide specifically or to the moisturizer itself – “long story short, niacinamide did seem to help the barrier function in this particular study,” Dr. Harper said. The takeaway, therefore, is that topical niacinamide treatments may offer some value to certain patients.
Moving on to licorice, Dr. Harper discussed an open label study recently published online in the Journal of the European Academy of Dermatology and Venereology, in which subjects were given a complete skin care system – which contained a cleanser, a day cream, a night cream, and a concealer product containing licochalcone A (licorice extract). They were evaluated over a period of 8 weeks for improvement in erythema, burning, stinging, tingling, and tightness, all of which were measured at baseline (J Eur Acad Dermatol Venereol. 2016 Feb;30 Suppl 1:21-7).
Results showed “improvement of statistical significance,” Dr. Harper said. “All groups had improvement over time, and did better at 8 weeks than at 4 weeks [although] the rosacea group did not reach statistical significance until week 8.”
Finally, with green tea, Dr. Harper pointed to a 2010 randomized double-blind split-face study of just four healthy individuals with erythema and telangiectasia of the face, treated for 6 weeks with a cream containing epigallocatechin-3-gallate (EGCG), the major catechin found in green tea, on one side of their face; a vehicle cream was applied to the other side and punch biopsies were performed to determine improvements (Int J Clin Exp Pathol. 2010;3[7]:705-9). EGCG cream was used because of its “antioxidant, immunomodulatory, photoprotective, antiangiogenic – that’s the standout here, that’s what we really need – and anti-inflammatory properties,” Dr. Harper said.
While biopsies did not reveal any changes to facial vasculature, there “was a significant reduction in hypoxia-inducible factor-1 and VEGF [vascular endothelial growth factor],” which are both markers of angiogenesis – indicating some degree of usefulness against rosacea, Dr. Harper said. However, a longer, more definitive study would be needed to substantiate these findings, she added.
Dr. Harper did not report any relevant financial disclosures.
ORLANDO – When treating rosacea, consider adding cosmeceuticals to more conventional prescriptions and over-the-counter treatments to improve the management of symptoms and patient satisfaction.
The recommendation comes from Dr. Julie Harper, a dermatologist at the University of Alabama-Birmingham, who spoke about the benefits of cosmeceuticals for rosacea at the Orlando Dermatology Aesthetic and Clinical Conference.
“I see about 40 people a day on my regular dermatology days [and] it’s easy to just write a prescription and hand it to that rosacea patient, but you do them a big disservice when you do that,” explained Dr. Harper. “We’ve got to talk about triggers, about skin care, about sun protection, [and] start that discussion from there.”
The most-important point for patients to understand is the main triggers of their rosacea, which can include ultraviolet light, spices, stress, exercise, heat, barrier disruption, and Demodex. Since sunlight is the No. 1 trigger for rosacea, treatment strategies often need to start there and revolve around how to avoid or manage the condition based on sun exposure.
As for cosmeceuticals, Dr. Harper focused on three types that have been shown to be effective against rosacea: niacinamide, licorice, and green tea.
The available data on niacinamide for rosacea are primarily from the 2006 Nicomide Improvement in Clinical Outcomes Study (NICOS), an open-label, multicenter, prospective cohort study that recruited people with acne vulgaris and acne rosacea from 100 centers and administered 750 mg of niacinamide with zinc and copper, while some got niacinamide plus oral antibiotics. The 49 people with rosacea who were enrolled received baseline assessments in the clinic, but 4-week and 8-week follow-ups were done via self-reported surveys (Cutis. 2006 Jan;77[1 Suppl]:17-28).
At 8 weeks, “75% of the rosacea group reported that appearance of their rosacea was moderately or much better [and] that there was also significant reduction in inflammatory lesions,” Dr. Harper said. “There was not a big difference in the group that had an oral antibiotic and niacinamide, versus niacinamide without the oral antibiotic,” although the design of the study leaves the findings somewhat questionable, she noted.
Topical niacinamide also has the potential to benefit certain rosacea patients, she said, referring to a 2005 study examining the effects of a niacinamide-containing moisturizer on the face and one forearm of 50 patients over 4 weeks. The primary outcome of the trial was barrier function, as measured by a dimethyl sulfoxide (DMSO) chemical probe (Cutis. 2005 Aug;76[2]:135-41).
While the results of this trial are “difficult” to interpret – due largely to the lack of any real measurement of facial improvement in barrier function and the confusion over whether any improvement on the forearm can be attributed to the niacinamide specifically or to the moisturizer itself – “long story short, niacinamide did seem to help the barrier function in this particular study,” Dr. Harper said. The takeaway, therefore, is that topical niacinamide treatments may offer some value to certain patients.
Moving on to licorice, Dr. Harper discussed an open label study recently published online in the Journal of the European Academy of Dermatology and Venereology, in which subjects were given a complete skin care system – which contained a cleanser, a day cream, a night cream, and a concealer product containing licochalcone A (licorice extract). They were evaluated over a period of 8 weeks for improvement in erythema, burning, stinging, tingling, and tightness, all of which were measured at baseline (J Eur Acad Dermatol Venereol. 2016 Feb;30 Suppl 1:21-7).
Results showed “improvement of statistical significance,” Dr. Harper said. “All groups had improvement over time, and did better at 8 weeks than at 4 weeks [although] the rosacea group did not reach statistical significance until week 8.”
Finally, with green tea, Dr. Harper pointed to a 2010 randomized double-blind split-face study of just four healthy individuals with erythema and telangiectasia of the face, treated for 6 weeks with a cream containing epigallocatechin-3-gallate (EGCG), the major catechin found in green tea, on one side of their face; a vehicle cream was applied to the other side and punch biopsies were performed to determine improvements (Int J Clin Exp Pathol. 2010;3[7]:705-9). EGCG cream was used because of its “antioxidant, immunomodulatory, photoprotective, antiangiogenic – that’s the standout here, that’s what we really need – and anti-inflammatory properties,” Dr. Harper said.
While biopsies did not reveal any changes to facial vasculature, there “was a significant reduction in hypoxia-inducible factor-1 and VEGF [vascular endothelial growth factor],” which are both markers of angiogenesis – indicating some degree of usefulness against rosacea, Dr. Harper said. However, a longer, more definitive study would be needed to substantiate these findings, she added.
Dr. Harper did not report any relevant financial disclosures.
AT THE ODAC CONFERENCE
Terminalia chebula
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Terminalia chebula
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Terminalia chebula, a member of the Combretaceae family, is an evergreen plant found abundantly in India, Pakistan, China, Thailand, Sri Lanka, and Malaysia.1,2 It has long been used in traditional medicine, particularly Ayurveda, as well as in Thai traditional medicine.3 It also has also been used for many years in the traditional medicine of the Samahni valley of Pakistan to treat chronic ulcers as well as dental caries and heart ailments.4 Other traditional indications include asthma and urinary disorders.5 In Thailand, it has been used to treat skin diseases and to promote wound healing and rejuvenation.1 It is particularly known for its potent antioxidant and antimicrobial properties.6 The wide array of health benefits associated with T. chebula is attributed to its high content of phenolic compounds, flavonol glycosides, and other phytonutrients.7
Antioxidant, anti-aging, and depigmenting effects
In 2004, Na et al. observed that T. chebula fruit extract exerted an inhibitory effect on the age-dependent shortening of telomeres and UVB-induced oxidative damage in vitro.8
Kim et al. screened 50 Korean plants to identify natural sources of elastase and hyaluronidase inhibitors in 2010. The strong efficacy of T. chebula led the investigators to choose it for additional study in which the fruits of the methanol crude extract at 1 mg/mL demonstrated 80% elastase and 87% hyaluronidase inhibitory activities. In addition, the investigators isolated 1,2,3,4,6-penta-O-galloyl-beta-D-glucose (PGG), which also exhibited significant inhibition of elastase and hyaluronidase and induction of type II collagen expression. The authors concluded that PGG has the potential as a cutaneous anti-aging agent posing no cytotoxicity concerns and warrants further in vivo study.9
A 2010 in vitro study of the anti-aging properties of the extracts of 15 plant species, including T. chebula galls, outgrowths that result from insect bites, was conducted by Manosroi et al. The cold aqueous extract of T. chebula manifested the highest 2,2-diphenyl-1-picrylhydrazyl (DPPH) radical-scavenging activity and highest stimulation index for proliferation of normal human skin fibroblasts. T. chebula, which also inhibited matrix metalloproteinase (MMP)-2 activity, was compared against compounds such as ascorbic acid, alpha-tocopherol, and butylated hydroxytoluene. The investigators concluded that their findings supported the traditional uses of T. chebula gall in Thai medicine and suggest that T. chebula would be beneficial for inclusion in new anti-aging formulations.3
Later that year, Manosroi et al. characterized the biological activities of the phenolic compounds isolated from T. chebula galls, finding that these compounds (gallic acid, punicalagin, isoterchebulin, 1,3,6-tri-O-galloyl-beta-D-glucopyranose, chebulagic acid, and chebulinic acid) exhibited greater radical-scavenging and melanin-inhibitory activity than the reference compounds ascorbic acid, butylated hydroxytoluene, alpha-tocopherol, arbutin, and kojic acid. Although the T. chebula constituents were less effective than the reference compounds in mushroom tyrosinase inhibition and human tumor cytotoxicity assays, the investigators concluded that the antioxidant and depigmenting activity of the constituents of T. chebula accounted for the beneficial profile of the plant that has emerged over time.10
The next year, Manosroi et al. assessed the cutaneous anti-aging effects of a gel containing niosomes incorporating a semi-purified fraction including gallic acid derived from T. chebula galls or outgrowths. Human volunteers were enlisted to test skin elasticity and roughness and rabbit skin was used to evaluate skin irritation. The gel containing the semi-purified fractions loaded in niosomes was compared with an unloaded fraction, revealing that the loaded niosomes yielded greater gallic acid chemical stability as well as in vivo anti-aging effects.11 Earlier that year, the team had shown the viability of niosomes, particularly elastic ones, to promote chemical stability for the transdermal absorption of gallic acid in semipurified T. chebula gall fractions in rats. Their findings, they concluded, point to the potential for achieving topical anti-aging benefits from such formulations.12
In 2012, Akhtar et al. developed a water-in-oil T. chebula formulation and assessed its effects on various parameters. The investigators prepared a base with no active ingredients and a 5% T. chebula formulation, which remained stable at various storage conditions. For 8 weeks, they applied the base as well as the formulation to the cheeks of human volunteers, with weekly evaluations indicating that the formulation as opposed to the base yielded significant improvement, irrespective of time elapsed, in skin moisture content and erythema. The authors concluded that their T. chebula topical cream was effective in rejuvenating human skin.13
Wound healing
In 2002, Suguna et al. investigated in vivo the effects of a topically administered alcohol extract of the leaves of T. chebula on the healing of rat dermal wounds. The researchers found that treatment with T. chebula accelerated wound healing, with improved contraction rates and shorter epithelialization periods. T. chebula treatment yielded a 40% increase in the tensile strength of tissues from treated wounds. The authors concluded that T. chebula is beneficial in speeding the wound healing process.2
Immature T. chebula fruit extracts high in tannins are thought to be effective in enhancing the wound healing process, according to Li et al., who found in 2011 that the extracts promoted wound healing in rats, likely due to the antibacterial and angiogenic potency of its tannins.1
In a 2014 study on wound healing, Singh et al. observed in vitro that T. chebula extracts effectively scavenged free radicals in a DPPH assay and enhanced proliferation of keratinocytes and fibroblasts. They concluded that T. chebula can be considered for use as a bioactive approach to wound healing for its effects in promoting cellular proliferation and inhibiting production of free radicals.7
Other biologic activities
A 1995 study by Kurokawa et al. showed that T. chebula was one of four herbal extracts among 10 tested to exhibit a discrete anti–herpes simplex virus type 1 (HSV-1) activity in vitro when combined with acyclovir. Oral administration of the herbs with acyclovir in mice in doses corresponding to human use significantly limited skin lesion development and/or extended mean survival time of infected mice in comparison to any of the herbs or acyclovir used alone.14
Nam et al. used a 2,4-dinitrofluorobenzene (DNFB)-induced mouse model of atopic symptoms in 2011 and found that a T. chebula seed extract attenuated atopic dermatitis symptoms, resulting in a 52% decrease in the immune response and lower eosinophil levels in nearby skin tissue.6
In 2013, Manosroi et al. found that various tannins and one oleanane-type triterpene acid isolated from T. chebula galls displayed strong inhibitory capacity against melanogenesis in mice, with one of the tannins (isoterchebulin) shown to decrease protein levels of tyrosinase, microphthalmia-associated transcription factor, and tyrosine-related protein 1 in mainly a concentration-dependent fashion. Another tannin and several triterpenoids were noted for suppressing 12-O-tetradecanoylphorbol 13-acetate (TPA)-induced inflammation. In addition, constituent phenols manifested strong radical-scavenging activity. In a two-stage carcinogenesis mouse model, the investigators observed that the triterpene acid arjungenin hindered skin tumor promotion after initiation with 7,12-dimethylbenz[a]anthracene (DMBA) and promotion by TPA. Their findings indicate a wide range of biologic activity and potential health benefits associated with T. chebula.15
In a mouse study in 2014, Singh et al. determined that a new antifungal agent, an apigenin ointment containing extract of T. chebula stem, was effective in significantly reducing the fungal burden from the experimentally-induced dermatophyte Trichopython mentagrophytes. They suggested that this agent warrants consideration in clinically treating dermatophytosis in humans.16
Triphala, a traditional combination formulation
Long used in Ayurveda, triphala (the word is derived from the Sanskrit tri, three, and phala, fruits) is an antioxidant-rich herbal formulation that combines the dried fruits of T. chebula, Terminalia bellirica, and Emblica officinalis. Naik et al. observed, in a 2005 in vitro study of the aqueous extract of the fruits of T. chebula, T. bellirica, and E. officinalis, as well as their equiproportional mixture triphala, that T. chebula was the most effective at scavenging free radicals. They noted that triphala appears to synergistically combine the strengths of each of its primary components.17 Subsequent studies have demonstrated that triphala is a strong source of natural antioxidants and exhibits a wide range of beneficial activities, including free radical scavenging, antioxidant, anti-inflammatory, analgesic, antibacterial, antimutagenic, wound healing, antistress, adaptogenic, hypoglycemic, anticancer, chemoprotective, radioprotective, chemopreventive, and wound healing.5,18-21
Extracts of T. chebula also have been combined with those of E. officinalis, T. bellirica, Albizia lebbeck, Piper nigrum, Zingiber officinale, and Piper longum in a polyherbal formulation (Aller-7/NR-A2) that has been found safe for the treatment of allergic rhinitis.22
Conclusion
The use of T. chebula in various traditional medical practices around the world is well established. There is ample evidence supporting multiple biologic properties of this Ayurvedic staple. While it is not a standard ingredient in dermatologic health care in the West, the data support continued research as to how best to incorporate this agent.
References
1. BMC Complement Altern Med. 2011 Oct 7;11:86.
2. Phytother Res. 2002 May;16(3):227-31.
3. Pharm Biol. 2010 Apr;48(4):469-81.
4. Pak J Biol Sci. 2007 Jul 1;10(13):2241-56.
5. BMC Complement Altern Med. 2010 May 13;10:20.
6. Int J Mol Med. 2011 Dec;28(6):1013-8.
7. Evid Based Complement Alternat Med. 2014;2014:701656.
8. Phytother Res. 2004 Sep;18:737-41.
9. Acta Pol Pharm. 2010 Mar-Apr;67(2):145-50.
10. Nat Prod Res. 2010 Dec;24(20):1915-26.
11. Pharm Biol. 2011 Nov;49(11):1190-203.
12. Pharm Biol. 2011 Jun;49(6):553-62.
13. Forsch Komplementmed. 2012;19(1):20-5.
14. Antiviral Res. 1995 May;27(1-2):19-37.
15. Chem Biodivers. 2013 Aug;10(8):1448-63.
16. Mycoses. 2014 Aug;57(8):497-506.
17. Phytother Res. 2005 Jul;19(7):582-6.
18. Chin J Integr Med. 2012 Dec;18(12):946-54.
19. J Surg Res. 2008 Jan;144(1):94-101.
20. J Surg Res. 2010 Jan;158(1):162-70.
21. J Altern Complement Med. 2010 Dec;16(12):1301-8.
22. Toxicol Mech Methods. 2005;15(3):193-204.
Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook, “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy, Topix Pharmaceuticals, and Unilever.
Cryolipolysis and Delayed Posttreatment Pain
Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.
An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.
In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.
Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.
Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.
What’s the issue?
Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?
Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.
An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.
In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.
Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.
Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.
What’s the issue?
Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?
Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.
An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.
In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.
Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.
Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.
What’s the issue?
Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?
Postinflammatory Hyperpigmentation in Patients With Skin of Color
Postinflammatory hyperpigmentation (PIH) develops as darkly pigmented macules that occur after an inflammatory process of the skin such as acne, folliculitis, eczema, or shaving irritation. Patients with Fitzpatrick skin types III to VI usually are most commonly affected, and for many, the remnant pigmentation can be an even greater concern than the original inflammatory process.1,2 Reported treatments of PIH include tretinoin, hydroquinone, azelaic acid, and chemical peels. The ideal combination of therapy has yet to be delineated.
Tretinoin (Vitamin A Derivative)
Bulengo-Ransby et al3 performed one of the first clinical trials testing tretinoin cream 0.1% for PIH in patients with Fitzpatrick skin types IV to VI . The study included 54 patients (24 applied tretinoin and 30 applied a vehicle) with moderate to severe PIH on the face and arms. The patients were divided into therapy and placebo groups and were evaluated for 40 weeks. Changes were evaluated through colorimetry, light microscopy, histology, and photography, with significant clinical improvement in the tretinoin-treated group (P<.001).3 A double-blind, randomized study of 45 photoaged Chinese and Japanese patients using tretinoin cream 0.1% also was conducted for treatment of photoaging-associated hyperpigmented lesions of the face and hands. Assessment was done with clinical, colorimetric, and histological evaluation, with an overall statistical improvement noted in hyperpigmentation.4 Both of the above studies showed mild irritation (ie, retinoid dermatitis) with application of tretinoin, which creates a compliance issue in patients who are recommended to continue therapy with higher-strength tretinoin. This side-effect profile can be circumvented through gradual elevation in the strength of tretinoin.5
Combination Therapies
Combination therapies with tretinoin also have been used to improve PIH. Callender et al6 conducted a study evaluating the efficacy of clindamycin phosphate 1.2%–tretinoin 0.025% gel for the treatment of PIH secondary to mild to moderate acne in patients with Fitzpatrick skin types IV to VI. Thirty patients participated in the randomized, double-blinded, placebo-controlled study, with 15 patients in the clindamycin-tretinoin gel group and 15 in the placebo control group. Based on objective assessment using a chromameter and evaluator global acne severity scale score, clinical efficacy was demonstrated for treating acne and PIH as well as preventing further PIH.6
Hydroquinone Formulation (Tyrosine Inhibitor)
Hydroquinone bleaching cream has been the standard therapy for hyperpigmentation. It works by blocking the conversion of dihydroxyphenylalanine to melanin by inhibiting tyrosinase.7 Topical steroids directly inhibit the synthesis of melanin, and when combined with hydroquinone and tretinoin, they can be effective for short periods of time and may decrease the irritation of application.7,8 The most widely accepted formula consists of a topical steroid (triamcinolone cream 0.1%) in combination with hydroquinone 4% and tretinoin cream 0.05%.8 In a similar 12-week open-label study of 25 patients with darker skin types, Grimes9 used an alternative combination formula of hydroquinone 4% and retinol 0.15%. Overall improvement and tolerance was demonstrated through the use of colorimetry measurement. A combination of hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% also has been used effectively for the treatment of melasma.10 This formulation has been used more anecdotally for the treatment of PIH and has yet to have a randomized-controlled trial. The concern with repeated long-term use of hydroquinone remains. Permanent leukoderma, exogenous ochronosis, and hyperpigmentation of the surrounding normal skin (halo effect) can occur.
Azelaic Acid (Tyrosinase Inhibitor)
Azelaic acid is a dicarboxylic acid isolated from pityriasis versicolor that acts similar to a tyrosine inhibitor and has an antiproliferative effect toward abnormal melanocytes. Lowe et al11 conducted a randomized, double-blind, vehicle-controlled trial in patients with Fitzpatrick skin types IV through VI with facial hyperpigmentation using azelaic acid cream 20%. Over the course of 24 weeks, patients noted a decrease in overall pigment using both an investigator subjective scale and chromometer analysis.11
Kojic Acid (Tyrosinase Inhibitor)
Kojic acid is a tyrosinase inhibitor found in fungal metabolite species such as Acetobacter, Aspergillus, and Penicillium. It is commonly combined with other skin lightening agents such as hydroquinone or vitamin C to further enhance its efficacy. A randomized, 12-week, split-face study of Chinese women with melasma compared treatment with a glycolic acid 10%–hydroquinone 2% gel versus the combination plus kojic acid 2%. The results showed that 60% (24/40) of patients improved with the use of kojic acid as compared to those using the medication without kojic acid.12 Anecdotal data suggest kojic acid may be effective for PIH13; however, no studies specifically for PIH have been conducted.
Chemical Peels
Chemical peels have been used for a number of years, though their benefits in patients with skin of color is still being elucidated. The ideal chemical peels for Fitzpatrick skin types IV through VI are superficial to medium-depth peeling agents and techniques.14 Glycolic acid is a naturally occurring α-hydroxy acid that causes an increase in collagen synthesis, stimulates epidermolysis, and disperses basal layer melanin. Neutralization of glycolic acid peels can be done with the use of water, sodium bicarbonate, or sodium hydroxide to avoid unnecessary epidermal damage. Multiple clinical trials have been conducted to determine the response of glycolic acid peels in clearing PIH in patients with skin of color. Kessler et al15 compared glycolic acid 30% to salicylic acid 30% in 20 patients with mild to moderate acne and associated PIH. Chemical peels were performed every 2 weeks for 12 weeks. The study showed that salicylic acid was better tolerated than glycolic acid and both were equally effective after the second application (P<.05) for PIH.15 Finally, another study conducted for PIH in patients with Fitzpatrick skin types III and IV utilized glycolic acid peels with 20%, 35%, and 70% concentrations. The results showed overall improvement of PIH and acne from the use of all concentrations of glycolic peels, though faster efficacy was noted at higher concentrations.16
Other self-neutralizing peeling agents include salicylic acid and Jessner solution. Salicylic acid is a β-hydroxy acid that works through keratolysis and disrupting intercellular linkages. Jessner solution is a combination of resorcinol 14%, lactic acid 14%, and salicylic acid 14% in an alcohol base. Salicylic acid is well-tolerated in patients with Fitzpatrick skin types I through VI and has been helpful in treating acne, rosacea, melasma, hyperpigmentation, texturally rough skin, and mild photoaging. Jessner peeling solution has been used for a number of years and works as a keratolytic agent causing intercellular and intracellular edema, and due to its self-neutralizing agent, it is fairly superficial.17 Overall, superficial peeling agents should be used on patients with darker skin types to avoid the risk for worsening dyspigmentation, keloid formation, or deep scarring.18
Conclusion
These treatments are only some of the topical and chemical modalities for PIH in patients with skin of color. The patient history, evaluation, skin type, and underlying medical problems should be considered prior to using any topical or peeling agent. Lastly, photoprotection should be heavily emphasized with both sun protective gear and use of broad-spectrum sunscreens with a high sun protection factor, as UV radiation can cause darkening of PIH areas regardless of skin type and can reverse the progress made by a given therapy.18
- Savory SA, Agim NG, Mao R, et al. Reliability assessment and validation of the postacne hyperpigmentation index (PAHPI), a new instrument to measure postinflammatory hyperpigmentation from acne vulgaris. J Am Acad Dermatol. 2014;70:108-114.
- Halder RM. The role of retinoids in the management of cutaneous conditions in blacks. J Am Acad Dermatol. 1998;39(2, pt 3):S98-S103.
- Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin (retinoid acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
- Griffiths CE, Goldfarb MT, Finkel LJ, et al. Topical tretinoin (retinoic acid) treatment of hyperpigmented lesions associated with photoaging in Chinese and Japanese patients: a vehicle-controlled trial. J Am Acad Dermatol. 1994;30:76-84.
- Callendar VD. Acne in ethnic skin: special considerations for therapy. Dermatol Ther. 2004;17:184-195.
- Callender VD, Young CM, Kindred C, et al. Efficacy and safety of clindamycin phosphate 1.2% and tretinoin 0.025% gel for the treatment of acne and acne-induced post-inflammatory hyperpigmentation in patients with skin of color. J Clin Aesthet Dermatol. 2012;5:25-32.
- Badreshia-Bansal S, Draelos ZD. Insight into skin lightening cosmeceuticals for women of color. J Drugs Dermatol. 2007;6:32-39.
- Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol. 1975;111:40-48.
- Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis. 2004;74:326-328.
- Chan R, Park KC, Lee MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. Br J Dermatol. 2008;159:697-703.
- Lowe NJ, Rizk D, Grimes P. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther. 1998;20:945-959.
- Lim JT. Treatment of melasma using kojic acid in a gel containing hydroquinone and glycolic acid. Dermatol Surg. 1999;25:282-284.
- Alexis AF, Blackcloud P. Natural ingredients for darker skin types: growing options for hyperpigmentation. J Drugs Dermatol. 2013;12:123-127.
- Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther. 2004;17:196-205.
- Kessler E, Flanagan K, Chia C, et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris [published online December 5, 2007]. Dermatol Surg. 2008;34:45-50, discussion 51.
- Erbağci Z, Akçali C. Biweekly serial glycolic acid peels vs. long-term daily use of topical low-strength glycolic acid in the treatment of atrophic acne scars. Int J Dermatol. 2000;39:789-794.
- Jackson A. Chemical peels [published online January 31, 2014]. Facial Plast Surg. 2014;30:26-34.
- Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
Postinflammatory hyperpigmentation (PIH) develops as darkly pigmented macules that occur after an inflammatory process of the skin such as acne, folliculitis, eczema, or shaving irritation. Patients with Fitzpatrick skin types III to VI usually are most commonly affected, and for many, the remnant pigmentation can be an even greater concern than the original inflammatory process.1,2 Reported treatments of PIH include tretinoin, hydroquinone, azelaic acid, and chemical peels. The ideal combination of therapy has yet to be delineated.
Tretinoin (Vitamin A Derivative)
Bulengo-Ransby et al3 performed one of the first clinical trials testing tretinoin cream 0.1% for PIH in patients with Fitzpatrick skin types IV to VI . The study included 54 patients (24 applied tretinoin and 30 applied a vehicle) with moderate to severe PIH on the face and arms. The patients were divided into therapy and placebo groups and were evaluated for 40 weeks. Changes were evaluated through colorimetry, light microscopy, histology, and photography, with significant clinical improvement in the tretinoin-treated group (P<.001).3 A double-blind, randomized study of 45 photoaged Chinese and Japanese patients using tretinoin cream 0.1% also was conducted for treatment of photoaging-associated hyperpigmented lesions of the face and hands. Assessment was done with clinical, colorimetric, and histological evaluation, with an overall statistical improvement noted in hyperpigmentation.4 Both of the above studies showed mild irritation (ie, retinoid dermatitis) with application of tretinoin, which creates a compliance issue in patients who are recommended to continue therapy with higher-strength tretinoin. This side-effect profile can be circumvented through gradual elevation in the strength of tretinoin.5
Combination Therapies
Combination therapies with tretinoin also have been used to improve PIH. Callender et al6 conducted a study evaluating the efficacy of clindamycin phosphate 1.2%–tretinoin 0.025% gel for the treatment of PIH secondary to mild to moderate acne in patients with Fitzpatrick skin types IV to VI. Thirty patients participated in the randomized, double-blinded, placebo-controlled study, with 15 patients in the clindamycin-tretinoin gel group and 15 in the placebo control group. Based on objective assessment using a chromameter and evaluator global acne severity scale score, clinical efficacy was demonstrated for treating acne and PIH as well as preventing further PIH.6
Hydroquinone Formulation (Tyrosine Inhibitor)
Hydroquinone bleaching cream has been the standard therapy for hyperpigmentation. It works by blocking the conversion of dihydroxyphenylalanine to melanin by inhibiting tyrosinase.7 Topical steroids directly inhibit the synthesis of melanin, and when combined with hydroquinone and tretinoin, they can be effective for short periods of time and may decrease the irritation of application.7,8 The most widely accepted formula consists of a topical steroid (triamcinolone cream 0.1%) in combination with hydroquinone 4% and tretinoin cream 0.05%.8 In a similar 12-week open-label study of 25 patients with darker skin types, Grimes9 used an alternative combination formula of hydroquinone 4% and retinol 0.15%. Overall improvement and tolerance was demonstrated through the use of colorimetry measurement. A combination of hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% also has been used effectively for the treatment of melasma.10 This formulation has been used more anecdotally for the treatment of PIH and has yet to have a randomized-controlled trial. The concern with repeated long-term use of hydroquinone remains. Permanent leukoderma, exogenous ochronosis, and hyperpigmentation of the surrounding normal skin (halo effect) can occur.
Azelaic Acid (Tyrosinase Inhibitor)
Azelaic acid is a dicarboxylic acid isolated from pityriasis versicolor that acts similar to a tyrosine inhibitor and has an antiproliferative effect toward abnormal melanocytes. Lowe et al11 conducted a randomized, double-blind, vehicle-controlled trial in patients with Fitzpatrick skin types IV through VI with facial hyperpigmentation using azelaic acid cream 20%. Over the course of 24 weeks, patients noted a decrease in overall pigment using both an investigator subjective scale and chromometer analysis.11
Kojic Acid (Tyrosinase Inhibitor)
Kojic acid is a tyrosinase inhibitor found in fungal metabolite species such as Acetobacter, Aspergillus, and Penicillium. It is commonly combined with other skin lightening agents such as hydroquinone or vitamin C to further enhance its efficacy. A randomized, 12-week, split-face study of Chinese women with melasma compared treatment with a glycolic acid 10%–hydroquinone 2% gel versus the combination plus kojic acid 2%. The results showed that 60% (24/40) of patients improved with the use of kojic acid as compared to those using the medication without kojic acid.12 Anecdotal data suggest kojic acid may be effective for PIH13; however, no studies specifically for PIH have been conducted.
Chemical Peels
Chemical peels have been used for a number of years, though their benefits in patients with skin of color is still being elucidated. The ideal chemical peels for Fitzpatrick skin types IV through VI are superficial to medium-depth peeling agents and techniques.14 Glycolic acid is a naturally occurring α-hydroxy acid that causes an increase in collagen synthesis, stimulates epidermolysis, and disperses basal layer melanin. Neutralization of glycolic acid peels can be done with the use of water, sodium bicarbonate, or sodium hydroxide to avoid unnecessary epidermal damage. Multiple clinical trials have been conducted to determine the response of glycolic acid peels in clearing PIH in patients with skin of color. Kessler et al15 compared glycolic acid 30% to salicylic acid 30% in 20 patients with mild to moderate acne and associated PIH. Chemical peels were performed every 2 weeks for 12 weeks. The study showed that salicylic acid was better tolerated than glycolic acid and both were equally effective after the second application (P<.05) for PIH.15 Finally, another study conducted for PIH in patients with Fitzpatrick skin types III and IV utilized glycolic acid peels with 20%, 35%, and 70% concentrations. The results showed overall improvement of PIH and acne from the use of all concentrations of glycolic peels, though faster efficacy was noted at higher concentrations.16
Other self-neutralizing peeling agents include salicylic acid and Jessner solution. Salicylic acid is a β-hydroxy acid that works through keratolysis and disrupting intercellular linkages. Jessner solution is a combination of resorcinol 14%, lactic acid 14%, and salicylic acid 14% in an alcohol base. Salicylic acid is well-tolerated in patients with Fitzpatrick skin types I through VI and has been helpful in treating acne, rosacea, melasma, hyperpigmentation, texturally rough skin, and mild photoaging. Jessner peeling solution has been used for a number of years and works as a keratolytic agent causing intercellular and intracellular edema, and due to its self-neutralizing agent, it is fairly superficial.17 Overall, superficial peeling agents should be used on patients with darker skin types to avoid the risk for worsening dyspigmentation, keloid formation, or deep scarring.18
Conclusion
These treatments are only some of the topical and chemical modalities for PIH in patients with skin of color. The patient history, evaluation, skin type, and underlying medical problems should be considered prior to using any topical or peeling agent. Lastly, photoprotection should be heavily emphasized with both sun protective gear and use of broad-spectrum sunscreens with a high sun protection factor, as UV radiation can cause darkening of PIH areas regardless of skin type and can reverse the progress made by a given therapy.18
Postinflammatory hyperpigmentation (PIH) develops as darkly pigmented macules that occur after an inflammatory process of the skin such as acne, folliculitis, eczema, or shaving irritation. Patients with Fitzpatrick skin types III to VI usually are most commonly affected, and for many, the remnant pigmentation can be an even greater concern than the original inflammatory process.1,2 Reported treatments of PIH include tretinoin, hydroquinone, azelaic acid, and chemical peels. The ideal combination of therapy has yet to be delineated.
Tretinoin (Vitamin A Derivative)
Bulengo-Ransby et al3 performed one of the first clinical trials testing tretinoin cream 0.1% for PIH in patients with Fitzpatrick skin types IV to VI . The study included 54 patients (24 applied tretinoin and 30 applied a vehicle) with moderate to severe PIH on the face and arms. The patients were divided into therapy and placebo groups and were evaluated for 40 weeks. Changes were evaluated through colorimetry, light microscopy, histology, and photography, with significant clinical improvement in the tretinoin-treated group (P<.001).3 A double-blind, randomized study of 45 photoaged Chinese and Japanese patients using tretinoin cream 0.1% also was conducted for treatment of photoaging-associated hyperpigmented lesions of the face and hands. Assessment was done with clinical, colorimetric, and histological evaluation, with an overall statistical improvement noted in hyperpigmentation.4 Both of the above studies showed mild irritation (ie, retinoid dermatitis) with application of tretinoin, which creates a compliance issue in patients who are recommended to continue therapy with higher-strength tretinoin. This side-effect profile can be circumvented through gradual elevation in the strength of tretinoin.5
Combination Therapies
Combination therapies with tretinoin also have been used to improve PIH. Callender et al6 conducted a study evaluating the efficacy of clindamycin phosphate 1.2%–tretinoin 0.025% gel for the treatment of PIH secondary to mild to moderate acne in patients with Fitzpatrick skin types IV to VI. Thirty patients participated in the randomized, double-blinded, placebo-controlled study, with 15 patients in the clindamycin-tretinoin gel group and 15 in the placebo control group. Based on objective assessment using a chromameter and evaluator global acne severity scale score, clinical efficacy was demonstrated for treating acne and PIH as well as preventing further PIH.6
Hydroquinone Formulation (Tyrosine Inhibitor)
Hydroquinone bleaching cream has been the standard therapy for hyperpigmentation. It works by blocking the conversion of dihydroxyphenylalanine to melanin by inhibiting tyrosinase.7 Topical steroids directly inhibit the synthesis of melanin, and when combined with hydroquinone and tretinoin, they can be effective for short periods of time and may decrease the irritation of application.7,8 The most widely accepted formula consists of a topical steroid (triamcinolone cream 0.1%) in combination with hydroquinone 4% and tretinoin cream 0.05%.8 In a similar 12-week open-label study of 25 patients with darker skin types, Grimes9 used an alternative combination formula of hydroquinone 4% and retinol 0.15%. Overall improvement and tolerance was demonstrated through the use of colorimetry measurement. A combination of hydroquinone 4%, tretinoin 0.05%, and fluocinolone acetonide 0.01% also has been used effectively for the treatment of melasma.10 This formulation has been used more anecdotally for the treatment of PIH and has yet to have a randomized-controlled trial. The concern with repeated long-term use of hydroquinone remains. Permanent leukoderma, exogenous ochronosis, and hyperpigmentation of the surrounding normal skin (halo effect) can occur.
Azelaic Acid (Tyrosinase Inhibitor)
Azelaic acid is a dicarboxylic acid isolated from pityriasis versicolor that acts similar to a tyrosine inhibitor and has an antiproliferative effect toward abnormal melanocytes. Lowe et al11 conducted a randomized, double-blind, vehicle-controlled trial in patients with Fitzpatrick skin types IV through VI with facial hyperpigmentation using azelaic acid cream 20%. Over the course of 24 weeks, patients noted a decrease in overall pigment using both an investigator subjective scale and chromometer analysis.11
Kojic Acid (Tyrosinase Inhibitor)
Kojic acid is a tyrosinase inhibitor found in fungal metabolite species such as Acetobacter, Aspergillus, and Penicillium. It is commonly combined with other skin lightening agents such as hydroquinone or vitamin C to further enhance its efficacy. A randomized, 12-week, split-face study of Chinese women with melasma compared treatment with a glycolic acid 10%–hydroquinone 2% gel versus the combination plus kojic acid 2%. The results showed that 60% (24/40) of patients improved with the use of kojic acid as compared to those using the medication without kojic acid.12 Anecdotal data suggest kojic acid may be effective for PIH13; however, no studies specifically for PIH have been conducted.
Chemical Peels
Chemical peels have been used for a number of years, though their benefits in patients with skin of color is still being elucidated. The ideal chemical peels for Fitzpatrick skin types IV through VI are superficial to medium-depth peeling agents and techniques.14 Glycolic acid is a naturally occurring α-hydroxy acid that causes an increase in collagen synthesis, stimulates epidermolysis, and disperses basal layer melanin. Neutralization of glycolic acid peels can be done with the use of water, sodium bicarbonate, or sodium hydroxide to avoid unnecessary epidermal damage. Multiple clinical trials have been conducted to determine the response of glycolic acid peels in clearing PIH in patients with skin of color. Kessler et al15 compared glycolic acid 30% to salicylic acid 30% in 20 patients with mild to moderate acne and associated PIH. Chemical peels were performed every 2 weeks for 12 weeks. The study showed that salicylic acid was better tolerated than glycolic acid and both were equally effective after the second application (P<.05) for PIH.15 Finally, another study conducted for PIH in patients with Fitzpatrick skin types III and IV utilized glycolic acid peels with 20%, 35%, and 70% concentrations. The results showed overall improvement of PIH and acne from the use of all concentrations of glycolic peels, though faster efficacy was noted at higher concentrations.16
Other self-neutralizing peeling agents include salicylic acid and Jessner solution. Salicylic acid is a β-hydroxy acid that works through keratolysis and disrupting intercellular linkages. Jessner solution is a combination of resorcinol 14%, lactic acid 14%, and salicylic acid 14% in an alcohol base. Salicylic acid is well-tolerated in patients with Fitzpatrick skin types I through VI and has been helpful in treating acne, rosacea, melasma, hyperpigmentation, texturally rough skin, and mild photoaging. Jessner peeling solution has been used for a number of years and works as a keratolytic agent causing intercellular and intracellular edema, and due to its self-neutralizing agent, it is fairly superficial.17 Overall, superficial peeling agents should be used on patients with darker skin types to avoid the risk for worsening dyspigmentation, keloid formation, or deep scarring.18
Conclusion
These treatments are only some of the topical and chemical modalities for PIH in patients with skin of color. The patient history, evaluation, skin type, and underlying medical problems should be considered prior to using any topical or peeling agent. Lastly, photoprotection should be heavily emphasized with both sun protective gear and use of broad-spectrum sunscreens with a high sun protection factor, as UV radiation can cause darkening of PIH areas regardless of skin type and can reverse the progress made by a given therapy.18
- Savory SA, Agim NG, Mao R, et al. Reliability assessment and validation of the postacne hyperpigmentation index (PAHPI), a new instrument to measure postinflammatory hyperpigmentation from acne vulgaris. J Am Acad Dermatol. 2014;70:108-114.
- Halder RM. The role of retinoids in the management of cutaneous conditions in blacks. J Am Acad Dermatol. 1998;39(2, pt 3):S98-S103.
- Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin (retinoid acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
- Griffiths CE, Goldfarb MT, Finkel LJ, et al. Topical tretinoin (retinoic acid) treatment of hyperpigmented lesions associated with photoaging in Chinese and Japanese patients: a vehicle-controlled trial. J Am Acad Dermatol. 1994;30:76-84.
- Callendar VD. Acne in ethnic skin: special considerations for therapy. Dermatol Ther. 2004;17:184-195.
- Callender VD, Young CM, Kindred C, et al. Efficacy and safety of clindamycin phosphate 1.2% and tretinoin 0.025% gel for the treatment of acne and acne-induced post-inflammatory hyperpigmentation in patients with skin of color. J Clin Aesthet Dermatol. 2012;5:25-32.
- Badreshia-Bansal S, Draelos ZD. Insight into skin lightening cosmeceuticals for women of color. J Drugs Dermatol. 2007;6:32-39.
- Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol. 1975;111:40-48.
- Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis. 2004;74:326-328.
- Chan R, Park KC, Lee MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. Br J Dermatol. 2008;159:697-703.
- Lowe NJ, Rizk D, Grimes P. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther. 1998;20:945-959.
- Lim JT. Treatment of melasma using kojic acid in a gel containing hydroquinone and glycolic acid. Dermatol Surg. 1999;25:282-284.
- Alexis AF, Blackcloud P. Natural ingredients for darker skin types: growing options for hyperpigmentation. J Drugs Dermatol. 2013;12:123-127.
- Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther. 2004;17:196-205.
- Kessler E, Flanagan K, Chia C, et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris [published online December 5, 2007]. Dermatol Surg. 2008;34:45-50, discussion 51.
- Erbağci Z, Akçali C. Biweekly serial glycolic acid peels vs. long-term daily use of topical low-strength glycolic acid in the treatment of atrophic acne scars. Int J Dermatol. 2000;39:789-794.
- Jackson A. Chemical peels [published online January 31, 2014]. Facial Plast Surg. 2014;30:26-34.
- Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
- Savory SA, Agim NG, Mao R, et al. Reliability assessment and validation of the postacne hyperpigmentation index (PAHPI), a new instrument to measure postinflammatory hyperpigmentation from acne vulgaris. J Am Acad Dermatol. 2014;70:108-114.
- Halder RM. The role of retinoids in the management of cutaneous conditions in blacks. J Am Acad Dermatol. 1998;39(2, pt 3):S98-S103.
- Bulengo-Ransby SM, Griffiths CE, Kimbrough-Green CK, et al. Topical tretinoin (retinoid acid) therapy for hyperpigmented lesions caused by inflammation of the skin in black patients. N Engl J Med. 1993;328:1438-1443.
- Griffiths CE, Goldfarb MT, Finkel LJ, et al. Topical tretinoin (retinoic acid) treatment of hyperpigmented lesions associated with photoaging in Chinese and Japanese patients: a vehicle-controlled trial. J Am Acad Dermatol. 1994;30:76-84.
- Callendar VD. Acne in ethnic skin: special considerations for therapy. Dermatol Ther. 2004;17:184-195.
- Callender VD, Young CM, Kindred C, et al. Efficacy and safety of clindamycin phosphate 1.2% and tretinoin 0.025% gel for the treatment of acne and acne-induced post-inflammatory hyperpigmentation in patients with skin of color. J Clin Aesthet Dermatol. 2012;5:25-32.
- Badreshia-Bansal S, Draelos ZD. Insight into skin lightening cosmeceuticals for women of color. J Drugs Dermatol. 2007;6:32-39.
- Kligman AM, Willis I. A new formula for depigmenting human skin. Arch Dermatol. 1975;111:40-48.
- Grimes PE. A microsponge formulation of hydroquinone 4% and retinol 0.15% in the treatment of melasma and postinflammatory hyperpigmentation. Cutis. 2004;74:326-328.
- Chan R, Park KC, Lee MH, et al. A randomized controlled trial of the efficacy and safety of a fixed triple combination (fluocinolone acetonide 0.01%, hydroquinone 4%, tretinoin 0.05%) compared with hydroquinone 4% cream in Asian patients with moderate to severe melasma. Br J Dermatol. 2008;159:697-703.
- Lowe NJ, Rizk D, Grimes P. Azelaic acid 20% cream in the treatment of facial hyperpigmentation in darker-skinned patients. Clin Ther. 1998;20:945-959.
- Lim JT. Treatment of melasma using kojic acid in a gel containing hydroquinone and glycolic acid. Dermatol Surg. 1999;25:282-284.
- Alexis AF, Blackcloud P. Natural ingredients for darker skin types: growing options for hyperpigmentation. J Drugs Dermatol. 2013;12:123-127.
- Roberts WE. Chemical peeling in ethnic/dark skin. Dermatol Ther. 2004;17:196-205.
- Kessler E, Flanagan K, Chia C, et al. Comparison of alpha- and beta-hydroxy acid chemical peels in the treatment of mild to moderately severe facial acne vulgaris [published online December 5, 2007]. Dermatol Surg. 2008;34:45-50, discussion 51.
- Erbağci Z, Akçali C. Biweekly serial glycolic acid peels vs. long-term daily use of topical low-strength glycolic acid in the treatment of atrophic acne scars. Int J Dermatol. 2000;39:789-794.
- Jackson A. Chemical peels [published online January 31, 2014]. Facial Plast Surg. 2014;30:26-34.
- Davis EC, Callender VD. Postinflammatory hyperpigmentation: a review of the epidemiology, clinical features, and treatment options in skin of color. J Clin Aesthet Dermatol. 2010;3:20-31.
Baux cut-points predict geriatric burn outcomes
SAN ANTONIO – Geriatric burn patients have less than a 50% chance of returning home with a Baux score of about 85, and the risk of death begins to climb steadily after a score 93, approaching 50% at 110 points and almost 100% at 130 points, according to a review of 8,001 elderly patients in the National Burn Repository.
The investigators are developing the findings into a decision-making tool to help counsel families and caregivers about their options when elderly loved ones are seriously burned.
“There’s just not a lot of data out there on prognosis after burn injury in the geriatric population. We thought a simple decision aid for discussion with key stakeholders would provide significant assistance,” said investigator Dr. Erica Hodgman, a surgery research resident at the University of Texas Southwestern Medical Center, Dallas.
The hope is that families and caregivers will be able to better judge if the patient would want to press on with treatment given the odds of returning home, being discharged to a skilled nursing or rehab facility, or dying. “I think it will help people” feel less guilty if they decide to withdraw care or not send patients far away to a burn center, she said at the Eastern Association for the Surgery of Trauma scientific assembly.
The Baux score, a well-known metric in the burn community, adds the patient’s age to the percentage of surface area burned, so a 70 year old patient burned over 23% of their body, for instance, would have a score of 93. A modified Baux score adds points for inhalation injuries, but because the data didn’t include inhalation injury severity, the investigators found it more useful to stick with the original formula.
They queried the repository for patients 65 years or older with second- or third-degree burns from 2002-2011. They excluded patients with a length of stay of a day or less, along with elective admissions, non-burn injuries, and transfers to other burn centers. Next, they calculated Baux scores for each of their 8,001 subjects and noted if the patients were discharged home or to an alternate facility, or if he or she died.
Most patients had moderate scores of 70-100, and almost half were sent home. Of the 1,509 that died in hospital, 264 (17.5%) had care withdraw at a median of 3 days, but a range of 0-231 days. Flames were the most common cause of injury, followed by scalding.
A receiver operating curve analysis found that a Baux score at or below 86.15 predicted discharge home (AUC 0.698, 75.28% sensitivity, 54.64% specificity); a score above 77.12 predicted discharge to an alternate setting (AUC 0.539, 74.91% sensitivity, 34.38% specificity); and a score above 93.3 predicted mortality (AUC 0.779, 57.46% sensitivity, 87.08% specificity).
Dr. Hodgman said she thinks the cut-points will remain useful even as burn care improves with new grafting techniques that require smaller donor sites. Such innovation will apply mostly to moderately injured patients; for the more severely injured, the predictive power of the findings should still hold.
The investigators have no disclosures.
SAN ANTONIO – Geriatric burn patients have less than a 50% chance of returning home with a Baux score of about 85, and the risk of death begins to climb steadily after a score 93, approaching 50% at 110 points and almost 100% at 130 points, according to a review of 8,001 elderly patients in the National Burn Repository.
The investigators are developing the findings into a decision-making tool to help counsel families and caregivers about their options when elderly loved ones are seriously burned.
“There’s just not a lot of data out there on prognosis after burn injury in the geriatric population. We thought a simple decision aid for discussion with key stakeholders would provide significant assistance,” said investigator Dr. Erica Hodgman, a surgery research resident at the University of Texas Southwestern Medical Center, Dallas.
The hope is that families and caregivers will be able to better judge if the patient would want to press on with treatment given the odds of returning home, being discharged to a skilled nursing or rehab facility, or dying. “I think it will help people” feel less guilty if they decide to withdraw care or not send patients far away to a burn center, she said at the Eastern Association for the Surgery of Trauma scientific assembly.
The Baux score, a well-known metric in the burn community, adds the patient’s age to the percentage of surface area burned, so a 70 year old patient burned over 23% of their body, for instance, would have a score of 93. A modified Baux score adds points for inhalation injuries, but because the data didn’t include inhalation injury severity, the investigators found it more useful to stick with the original formula.
They queried the repository for patients 65 years or older with second- or third-degree burns from 2002-2011. They excluded patients with a length of stay of a day or less, along with elective admissions, non-burn injuries, and transfers to other burn centers. Next, they calculated Baux scores for each of their 8,001 subjects and noted if the patients were discharged home or to an alternate facility, or if he or she died.
Most patients had moderate scores of 70-100, and almost half were sent home. Of the 1,509 that died in hospital, 264 (17.5%) had care withdraw at a median of 3 days, but a range of 0-231 days. Flames were the most common cause of injury, followed by scalding.
A receiver operating curve analysis found that a Baux score at or below 86.15 predicted discharge home (AUC 0.698, 75.28% sensitivity, 54.64% specificity); a score above 77.12 predicted discharge to an alternate setting (AUC 0.539, 74.91% sensitivity, 34.38% specificity); and a score above 93.3 predicted mortality (AUC 0.779, 57.46% sensitivity, 87.08% specificity).
Dr. Hodgman said she thinks the cut-points will remain useful even as burn care improves with new grafting techniques that require smaller donor sites. Such innovation will apply mostly to moderately injured patients; for the more severely injured, the predictive power of the findings should still hold.
The investigators have no disclosures.
SAN ANTONIO – Geriatric burn patients have less than a 50% chance of returning home with a Baux score of about 85, and the risk of death begins to climb steadily after a score 93, approaching 50% at 110 points and almost 100% at 130 points, according to a review of 8,001 elderly patients in the National Burn Repository.
The investigators are developing the findings into a decision-making tool to help counsel families and caregivers about their options when elderly loved ones are seriously burned.
“There’s just not a lot of data out there on prognosis after burn injury in the geriatric population. We thought a simple decision aid for discussion with key stakeholders would provide significant assistance,” said investigator Dr. Erica Hodgman, a surgery research resident at the University of Texas Southwestern Medical Center, Dallas.
The hope is that families and caregivers will be able to better judge if the patient would want to press on with treatment given the odds of returning home, being discharged to a skilled nursing or rehab facility, or dying. “I think it will help people” feel less guilty if they decide to withdraw care or not send patients far away to a burn center, she said at the Eastern Association for the Surgery of Trauma scientific assembly.
The Baux score, a well-known metric in the burn community, adds the patient’s age to the percentage of surface area burned, so a 70 year old patient burned over 23% of their body, for instance, would have a score of 93. A modified Baux score adds points for inhalation injuries, but because the data didn’t include inhalation injury severity, the investigators found it more useful to stick with the original formula.
They queried the repository for patients 65 years or older with second- or third-degree burns from 2002-2011. They excluded patients with a length of stay of a day or less, along with elective admissions, non-burn injuries, and transfers to other burn centers. Next, they calculated Baux scores for each of their 8,001 subjects and noted if the patients were discharged home or to an alternate facility, or if he or she died.
Most patients had moderate scores of 70-100, and almost half were sent home. Of the 1,509 that died in hospital, 264 (17.5%) had care withdraw at a median of 3 days, but a range of 0-231 days. Flames were the most common cause of injury, followed by scalding.
A receiver operating curve analysis found that a Baux score at or below 86.15 predicted discharge home (AUC 0.698, 75.28% sensitivity, 54.64% specificity); a score above 77.12 predicted discharge to an alternate setting (AUC 0.539, 74.91% sensitivity, 34.38% specificity); and a score above 93.3 predicted mortality (AUC 0.779, 57.46% sensitivity, 87.08% specificity).
Dr. Hodgman said she thinks the cut-points will remain useful even as burn care improves with new grafting techniques that require smaller donor sites. Such innovation will apply mostly to moderately injured patients; for the more severely injured, the predictive power of the findings should still hold.
The investigators have no disclosures.
AT THE EAST SCIENTIFIC ASSEMBLY
Key clinical point: Baux score cut-points help counsel families about their options when an elderly family member is seriously burned.
Major finding: Geriatric burn patients have less than a 50% chance of returning home with a Baux score of about 85, and the risk of death begins to climb steadily after a score 93.
Data source: Review of 8,001 patients over 65 years old in the National Burn Repository
Disclosures: The investigators have no disclosures.
Pretreatment hydroquinone for nonablative laser resurfacing of acne scars?
Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?
For ablative CO2 resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.1 The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?
In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.
For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.4,5
Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.
If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.6 In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.
In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.
References
1. Dermatol Surg. 1999 Jan;25(1):15-7.
2. Dermatol Surg. 2010 May;36(5):602-9.
3. Br J Dermatol. 2012 Jun;166(6):1160-9.
4.Lasers Surg Med. 2007 Jun;39(5):381-5.
5. Lasers Surg Med. 2007 Apr;39(4):311-4.
6. Dermatol Surg. 2010 Jun;36(6):909-18.
Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.
Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?
For ablative CO2 resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.1 The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?
In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.
For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.4,5
Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.
If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.6 In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.
In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.
References
1. Dermatol Surg. 1999 Jan;25(1):15-7.
2. Dermatol Surg. 2010 May;36(5):602-9.
3. Br J Dermatol. 2012 Jun;166(6):1160-9.
4.Lasers Surg Med. 2007 Jun;39(5):381-5.
5. Lasers Surg Med. 2007 Apr;39(4):311-4.
6. Dermatol Surg. 2010 Jun;36(6):909-18.
Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.
Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?
For ablative CO2 resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.1 The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?
In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.
For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.4,5
Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.
If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.6 In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.
In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.
References
1. Dermatol Surg. 1999 Jan;25(1):15-7.
2. Dermatol Surg. 2010 May;36(5):602-9.
3. Br J Dermatol. 2012 Jun;166(6):1160-9.
4.Lasers Surg Med. 2007 Jun;39(5):381-5.
5. Lasers Surg Med. 2007 Apr;39(4):311-4.
6. Dermatol Surg. 2010 Jun;36(6):909-18.
Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.
Novel oval ruby laser zaps blue-green tattoo pigments
HOLLYWOOD, FL. – Tattoos are common, but so are regrets. As tattoos become acceptable for the American mainstream, physicians are seeing more people who, for personal or professional reasons, wish to have a tattoo removed. And those who perform removal procedures benefit from having tools in their toolkit to eradicate an unwanted tattoo with minimal lasting skin damage.
Even with laser therapy – a common and effective tattoo removal technique – blue and green pigments can be especially difficult to eradicate.
At the annual meeting of the American Academy of Cosmetic Surgery, Dr. Robert H. Burke, director of the Michigan Center for Cosmetic Surgery, Ann Arbor, shared results from a pilot study of removal of blue-green pigments with a unique oval-shaped beam from a ruby laser.
Lasers, which preferentially heat chromophores, work well for tattoo removal since a selected wavelength is preferentially absorbed by a particular chromophore, targeting tattooed tissue and sparing non-inked tissue.
Older laser technologies created a Gaussian distribution of intensity with decreasing energy distribution toward the perimeter of the laser field. Newer lasers can create a sharper focal beam, creating beams of different sizes and shapes with uniform intensity.
In the pilot study, four men and four women who had persistent blue-green tattoo colors, received treatment with a 694 nm uniform-intensity ruby laser with an oval beam configuration. The patients, whose mean age was about 31 years, had tattoos with an age range of four to 30 years. The mean age of tattoos was 11.4 years. Most patients had had prior tattoo removal sessions; one of the women had undergone 14 sessions.
Dr. Burke treated these patients two to four times with the oval beam 694 nm ruby laser; fluence ranged from 2-5 J/cm2, with a spot size of 4-6 mm and a cycle of 2Hz.
The average tattoo pigment color clearance achieved with the oval beam 694 nm ruby laser was 60%, with a range from 40% to 90%. The study participants experienced no adverse events, Dr. Burke said.
The oval beam shape, he noted, deserves further investigation, because it should theoretically create less overlap and permit denser treatment – and may also allow the operator to follow a linear tattoo pattern more closely. This particular treatment regimen was also quicker, using 2 Hz rather than the more common 1 Hz, he pointed out.
Dr. Burke reported being on the physician advisory board for Suneva Medical.
On Twitter @karioakes
HOLLYWOOD, FL. – Tattoos are common, but so are regrets. As tattoos become acceptable for the American mainstream, physicians are seeing more people who, for personal or professional reasons, wish to have a tattoo removed. And those who perform removal procedures benefit from having tools in their toolkit to eradicate an unwanted tattoo with minimal lasting skin damage.
Even with laser therapy – a common and effective tattoo removal technique – blue and green pigments can be especially difficult to eradicate.
At the annual meeting of the American Academy of Cosmetic Surgery, Dr. Robert H. Burke, director of the Michigan Center for Cosmetic Surgery, Ann Arbor, shared results from a pilot study of removal of blue-green pigments with a unique oval-shaped beam from a ruby laser.
Lasers, which preferentially heat chromophores, work well for tattoo removal since a selected wavelength is preferentially absorbed by a particular chromophore, targeting tattooed tissue and sparing non-inked tissue.
Older laser technologies created a Gaussian distribution of intensity with decreasing energy distribution toward the perimeter of the laser field. Newer lasers can create a sharper focal beam, creating beams of different sizes and shapes with uniform intensity.
In the pilot study, four men and four women who had persistent blue-green tattoo colors, received treatment with a 694 nm uniform-intensity ruby laser with an oval beam configuration. The patients, whose mean age was about 31 years, had tattoos with an age range of four to 30 years. The mean age of tattoos was 11.4 years. Most patients had had prior tattoo removal sessions; one of the women had undergone 14 sessions.
Dr. Burke treated these patients two to four times with the oval beam 694 nm ruby laser; fluence ranged from 2-5 J/cm2, with a spot size of 4-6 mm and a cycle of 2Hz.
The average tattoo pigment color clearance achieved with the oval beam 694 nm ruby laser was 60%, with a range from 40% to 90%. The study participants experienced no adverse events, Dr. Burke said.
The oval beam shape, he noted, deserves further investigation, because it should theoretically create less overlap and permit denser treatment – and may also allow the operator to follow a linear tattoo pattern more closely. This particular treatment regimen was also quicker, using 2 Hz rather than the more common 1 Hz, he pointed out.
Dr. Burke reported being on the physician advisory board for Suneva Medical.
On Twitter @karioakes
HOLLYWOOD, FL. – Tattoos are common, but so are regrets. As tattoos become acceptable for the American mainstream, physicians are seeing more people who, for personal or professional reasons, wish to have a tattoo removed. And those who perform removal procedures benefit from having tools in their toolkit to eradicate an unwanted tattoo with minimal lasting skin damage.
Even with laser therapy – a common and effective tattoo removal technique – blue and green pigments can be especially difficult to eradicate.
At the annual meeting of the American Academy of Cosmetic Surgery, Dr. Robert H. Burke, director of the Michigan Center for Cosmetic Surgery, Ann Arbor, shared results from a pilot study of removal of blue-green pigments with a unique oval-shaped beam from a ruby laser.
Lasers, which preferentially heat chromophores, work well for tattoo removal since a selected wavelength is preferentially absorbed by a particular chromophore, targeting tattooed tissue and sparing non-inked tissue.
Older laser technologies created a Gaussian distribution of intensity with decreasing energy distribution toward the perimeter of the laser field. Newer lasers can create a sharper focal beam, creating beams of different sizes and shapes with uniform intensity.
In the pilot study, four men and four women who had persistent blue-green tattoo colors, received treatment with a 694 nm uniform-intensity ruby laser with an oval beam configuration. The patients, whose mean age was about 31 years, had tattoos with an age range of four to 30 years. The mean age of tattoos was 11.4 years. Most patients had had prior tattoo removal sessions; one of the women had undergone 14 sessions.
Dr. Burke treated these patients two to four times with the oval beam 694 nm ruby laser; fluence ranged from 2-5 J/cm2, with a spot size of 4-6 mm and a cycle of 2Hz.
The average tattoo pigment color clearance achieved with the oval beam 694 nm ruby laser was 60%, with a range from 40% to 90%. The study participants experienced no adverse events, Dr. Burke said.
The oval beam shape, he noted, deserves further investigation, because it should theoretically create less overlap and permit denser treatment – and may also allow the operator to follow a linear tattoo pattern more closely. This particular treatment regimen was also quicker, using 2 Hz rather than the more common 1 Hz, he pointed out.
Dr. Burke reported being on the physician advisory board for Suneva Medical.
On Twitter @karioakes
AT THE AACS ANNUAL MEETING
Key clinical point: A novel oval-shaped ruby laser improved the removal of resistant blue-green tattoo pigments.
Major finding: A pilot study found an average 60% reduction in blue and green tattoo pigments with a novel oval-shaped ruby laser beam.
Data source: Eight patients, most of whom were pretreated, seeking removal of tattoos with resistant blue and great pigments.
Disclosures: Dr. Burke reported being on the physician advisory board for Suneva Medical.
