Aesthetic Dermatology

ORLANDO – The first time a man walks in for an aesthetic consultation, he probably doesn’t know what to expect, according to Terrence Keaney, MD, a dermatologist in private practice in Arlington, Va. And he may not even be sure what he’s looking for.

However, he probably knows what he doesn’t like about his appearance. When men are questioned, the three areas they are most concerned about is their hairline, their eyes, and their jawline, said Dr. Keaney, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

It’s important to evaluate men differently, not just for anatomic differences from women, but also for behavioral and psychological factors unique to men as aesthetic patients, he noted.

Anatomic differences are significant and fundamentally shape treatment decisions, Dr. Keaney said. Broadly speaking, “the male face is traditionally more square, with a prominent supraorbital ridge.” Rather than emphasizing breadth across the cheeks, as in rejuvenation for women, a strong, youthful male face will have a square jaw, appropriate width across the cheeks, and a strong brow line with an arch that is flatter than what women seek.

Male cosmetic goals can be complicated by the fact that men “age poorly” and tend to look older than their stated age, he continued, referring to a study that found that men appear about one-third year older than their age, and women about a half year younger. A higher rate of smoking and excess ultraviolet light exposure among men may contribute to this discrepancy, he said.

Overall, men see steady atrophy of facial soft tissue throughout adulthood, in contrast to women who see a more rapid decline that starts at menopause. This makes sense in the context of the slow drop in circulating testosterone that men see beginning at about age 30, at which time men can expect a decrease of about 1% per year, he noted.

A common opener from men, said Dr. Keaney, is “’I look tired.’ When I hear that, I’m thinking about the eyes.” Men are more likely to develop tear troughs and a sunken appearance because of their larger orbital cavities and smaller orbital fat pads, so periocular fillers are often a treatment tool to consider.

Around mens’ eyes, “it’s not just the presence, but the pattern of wrinkles that guides treatment,” he noted. At the lateral canthi, both at rest and with maximum smile, the predominant wrinkle pattern in crows’ feet is the lower fan. The cheek elevator musculature, including the zygomaticus major, are more involved in animation around the eyes with smiling, which is important because reaching for botulinum toxin alone is probably not going to give the patient his desired effect, he added.

Other differences in the male wrinkle pattern can be found on the brow. The “U” contraction pattern between the brows is more common in men than women, at least partly because men have greater involvement of the procerus muscle, Dr. Keaney said.

Taking all of this into account, caution is the watchword when using botulinum toxin for the glabellar and brow region. “Beware of eyebrow ptosis: avoid the frontalis in patients with eyebrow ptosis,” he said. Treating the corrugators can also be an unwise move, since toxin can diffuse to the inferior fibers of the frontalis muscle, he added.

For men with jawline concerns, consider a combination approach, Dr. Keaney said. The lower face and neck can be rejuvenated by a redraping solution, such as skin tightening with high frequency ultrasound or radiofrequency ablation.

Sometimes, a clean, tight sweep of jawline can be restored with dermal fillers to the lower face, along with a noninvasive fat reduction approach, said Dr. Keaney.

Knowing men’s unique anatomy and aging patterns is only half the battle, though. “How you communicate with men and evaluate them has to take into account that you might be seeing a sweaty, nervous, treatment-naive patient,” at the initial consultation, said Dr. Keaney. “Do men care? Yes, but men display a different set of motivations.”

Plan for all of this to take time. “The initial consultation tends to be longer” for male patients, who are “less savvy” about cosmetic procedures than women, he pointed out.

A clear discussion of side effects is critical when discussing treatment options with men. “If they get a side effect, you’ll never see them again – and you won’t ever hear about it,” he added.

Though overall, women have been shown to be more sensitive to pain, in cosmetic procedures, “men are less tolerant of pain.” Plan for this, set reasonable expectations but be proactive about pain control, and still expect a need for some hand-holding, said Dr. Keaney.

“Men do not like surprises,” he added. Clearly define what expected side effects may be, what they’ll look like, and what downtime the patient should expect.

For Dr. Keaney’s part, he’s found that the best way to retain men in his cosmetic practice is to “start with a home run treatment to earn trust.” Men often appreciate a slow and steady approach to addressing concerns. “Make sure to connect the treatment plan to the primary cosmetic concern.”

Dr. Keaney reported that he has relationships with multiple pharmaceutical and cosmetic companies.

koakes@mdedge.com

ORLANDO – The first time a man walks in for an aesthetic consultation, he probably doesn’t know what to expect, according to Terrence Keaney, MD, a dermatologist in private practice in Arlington, Va. And he may not even be sure what he’s looking for.

However, he probably knows what he doesn’t like about his appearance. When men are questioned, the three areas they are most concerned about is their hairline, their eyes, and their jawline, said Dr. Keaney, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

It’s important to evaluate men differently, not just for anatomic differences from women, but also for behavioral and psychological factors unique to men as aesthetic patients, he noted.

Anatomic differences are significant and fundamentally shape treatment decisions, Dr. Keaney said. Broadly speaking, “the male face is traditionally more square, with a prominent supraorbital ridge.” Rather than emphasizing breadth across the cheeks, as in rejuvenation for women, a strong, youthful male face will have a square jaw, appropriate width across the cheeks, and a strong brow line with an arch that is flatter than what women seek.

Male cosmetic goals can be complicated by the fact that men “age poorly” and tend to look older than their stated age, he continued, referring to a study that found that men appear about one-third year older than their age, and women about a half year younger. A higher rate of smoking and excess ultraviolet light exposure among men may contribute to this discrepancy, he said.

Overall, men see steady atrophy of facial soft tissue throughout adulthood, in contrast to women who see a more rapid decline that starts at menopause. This makes sense in the context of the slow drop in circulating testosterone that men see beginning at about age 30, at which time men can expect a decrease of about 1% per year, he noted.

A common opener from men, said Dr. Keaney, is “’I look tired.’ When I hear that, I’m thinking about the eyes.” Men are more likely to develop tear troughs and a sunken appearance because of their larger orbital cavities and smaller orbital fat pads, so periocular fillers are often a treatment tool to consider.

Around mens’ eyes, “it’s not just the presence, but the pattern of wrinkles that guides treatment,” he noted. At the lateral canthi, both at rest and with maximum smile, the predominant wrinkle pattern in crows’ feet is the lower fan. The cheek elevator musculature, including the zygomaticus major, are more involved in animation around the eyes with smiling, which is important because reaching for botulinum toxin alone is probably not going to give the patient his desired effect, he added.

Other differences in the male wrinkle pattern can be found on the brow. The “U” contraction pattern between the brows is more common in men than women, at least partly because men have greater involvement of the procerus muscle, Dr. Keaney said.

Taking all of this into account, caution is the watchword when using botulinum toxin for the glabellar and brow region. “Beware of eyebrow ptosis: avoid the frontalis in patients with eyebrow ptosis,” he said. Treating the corrugators can also be an unwise move, since toxin can diffuse to the inferior fibers of the frontalis muscle, he added.

For men with jawline concerns, consider a combination approach, Dr. Keaney said. The lower face and neck can be rejuvenated by a redraping solution, such as skin tightening with high frequency ultrasound or radiofrequency ablation.

Sometimes, a clean, tight sweep of jawline can be restored with dermal fillers to the lower face, along with a noninvasive fat reduction approach, said Dr. Keaney.

Knowing men’s unique anatomy and aging patterns is only half the battle, though. “How you communicate with men and evaluate them has to take into account that you might be seeing a sweaty, nervous, treatment-naive patient,” at the initial consultation, said Dr. Keaney. “Do men care? Yes, but men display a different set of motivations.”

Plan for all of this to take time. “The initial consultation tends to be longer” for male patients, who are “less savvy” about cosmetic procedures than women, he pointed out.

A clear discussion of side effects is critical when discussing treatment options with men. “If they get a side effect, you’ll never see them again – and you won’t ever hear about it,” he added.

Though overall, women have been shown to be more sensitive to pain, in cosmetic procedures, “men are less tolerant of pain.” Plan for this, set reasonable expectations but be proactive about pain control, and still expect a need for some hand-holding, said Dr. Keaney.

“Men do not like surprises,” he added. Clearly define what expected side effects may be, what they’ll look like, and what downtime the patient should expect.

For Dr. Keaney’s part, he’s found that the best way to retain men in his cosmetic practice is to “start with a home run treatment to earn trust.” Men often appreciate a slow and steady approach to addressing concerns. “Make sure to connect the treatment plan to the primary cosmetic concern.”

Dr. Keaney reported that he has relationships with multiple pharmaceutical and cosmetic companies.

koakes@mdedge.com

ORLANDO – The first time a man walks in for an aesthetic consultation, he probably doesn’t know what to expect, according to Terrence Keaney, MD, a dermatologist in private practice in Arlington, Va. And he may not even be sure what he’s looking for.

However, he probably knows what he doesn’t like about his appearance. When men are questioned, the three areas they are most concerned about is their hairline, their eyes, and their jawline, said Dr. Keaney, speaking at the Orlando Dermatology Aesthetic and Clinical Conference.

It’s important to evaluate men differently, not just for anatomic differences from women, but also for behavioral and psychological factors unique to men as aesthetic patients, he noted.

Anatomic differences are significant and fundamentally shape treatment decisions, Dr. Keaney said. Broadly speaking, “the male face is traditionally more square, with a prominent supraorbital ridge.” Rather than emphasizing breadth across the cheeks, as in rejuvenation for women, a strong, youthful male face will have a square jaw, appropriate width across the cheeks, and a strong brow line with an arch that is flatter than what women seek.

Male cosmetic goals can be complicated by the fact that men “age poorly” and tend to look older than their stated age, he continued, referring to a study that found that men appear about one-third year older than their age, and women about a half year younger. A higher rate of smoking and excess ultraviolet light exposure among men may contribute to this discrepancy, he said.

Overall, men see steady atrophy of facial soft tissue throughout adulthood, in contrast to women who see a more rapid decline that starts at menopause. This makes sense in the context of the slow drop in circulating testosterone that men see beginning at about age 30, at which time men can expect a decrease of about 1% per year, he noted.

A common opener from men, said Dr. Keaney, is “’I look tired.’ When I hear that, I’m thinking about the eyes.” Men are more likely to develop tear troughs and a sunken appearance because of their larger orbital cavities and smaller orbital fat pads, so periocular fillers are often a treatment tool to consider.

Around mens’ eyes, “it’s not just the presence, but the pattern of wrinkles that guides treatment,” he noted. At the lateral canthi, both at rest and with maximum smile, the predominant wrinkle pattern in crows’ feet is the lower fan. The cheek elevator musculature, including the zygomaticus major, are more involved in animation around the eyes with smiling, which is important because reaching for botulinum toxin alone is probably not going to give the patient his desired effect, he added.

Other differences in the male wrinkle pattern can be found on the brow. The “U” contraction pattern between the brows is more common in men than women, at least partly because men have greater involvement of the procerus muscle, Dr. Keaney said.

Taking all of this into account, caution is the watchword when using botulinum toxin for the glabellar and brow region. “Beware of eyebrow ptosis: avoid the frontalis in patients with eyebrow ptosis,” he said. Treating the corrugators can also be an unwise move, since toxin can diffuse to the inferior fibers of the frontalis muscle, he added.

For men with jawline concerns, consider a combination approach, Dr. Keaney said. The lower face and neck can be rejuvenated by a redraping solution, such as skin tightening with high frequency ultrasound or radiofrequency ablation.

Sometimes, a clean, tight sweep of jawline can be restored with dermal fillers to the lower face, along with a noninvasive fat reduction approach, said Dr. Keaney.

Knowing men’s unique anatomy and aging patterns is only half the battle, though. “How you communicate with men and evaluate them has to take into account that you might be seeing a sweaty, nervous, treatment-naive patient,” at the initial consultation, said Dr. Keaney. “Do men care? Yes, but men display a different set of motivations.”

Plan for all of this to take time. “The initial consultation tends to be longer” for male patients, who are “less savvy” about cosmetic procedures than women, he pointed out.

A clear discussion of side effects is critical when discussing treatment options with men. “If they get a side effect, you’ll never see them again – and you won’t ever hear about it,” he added.

Though overall, women have been shown to be more sensitive to pain, in cosmetic procedures, “men are less tolerant of pain.” Plan for this, set reasonable expectations but be proactive about pain control, and still expect a need for some hand-holding, said Dr. Keaney.

“Men do not like surprises,” he added. Clearly define what expected side effects may be, what they’ll look like, and what downtime the patient should expect.

For Dr. Keaney’s part, he’s found that the best way to retain men in his cosmetic practice is to “start with a home run treatment to earn trust.” Men often appreciate a slow and steady approach to addressing concerns. “Make sure to connect the treatment plan to the primary cosmetic concern.”

Dr. Keaney reported that he has relationships with multiple pharmaceutical and cosmetic companies.

koakes@mdedge.com

ORLANDO – Platelet-rich plasma offers much for patients and dermatologists: It’s low-risk, has a low cost of entry, and usefully augments other medications and procedures for androgenetic alopecia and facial rejuvenation.

But there’s work to be done in standardizing its use and really understanding where, when, and for whom platelet-rich plasma (PRP) will be best used, said Dierdre Hooper, MD, a dermatologist in private practice in New Orleans.

As far back as the 1970s, PRP was used as a transfusion product, with use expanding during the following decade. “It’s really the ‘everywhere’ product,’” said Dr. Hooper, speaking at the Aesthetic, Surgical, and Clinical Dermatology Conference (ODAC).

Over the course of the past four decades, PRP has been explored for musculoskeletal healing, in gynecology, urology, cardiac surgery, ophthalmology, and for plastic surgery. “Initial skepticism has given way as some evidence is building,” said Dr. Hooper.

PRP, considered a biologic product, is produced by centrifuging a donor venipuncture. Among the pros of using PRP in a clinical practice, said Dr. Hooper, is the fact that numerous clinical studies do show benefit. The risk is low, as is the cost, and downtime is brief. All of these contribute to attractiveness to patients, who also like the idea of an all-natural product with an autologous source.

But consensus is lacking about some key aspects of utilization, including the best mode of preparation and optimal treatment schedule. Outcomes can be unpredictable, making it tough to say how cost-effective the regimen will be for a particular patient. “The ‘cons’ just come down to no consensus,” said Dr. Hooper.

Some of the basic science makes a compelling case for PRP: Activated platelets have secretory granules. These modify the pericellular milieu through release of a variety of growth factors by secretory granules. “We all were taught back in the day that platelets adhere to promote clotting, but they do a lot more than that – when the platelet is activated, it releases growth factors,” said Dr. Hooper. “Big picture? Think: This is how we heal.”

After blood collection, the sample is centrifuged. The goal of centrifuging is to achieve a platelet concentration of 1 to 1.5 million platelets per mL, or four to six times the platelet concentration seen in whole blood. In practice, there are variations in the mode of preparation, and in an individual’s platelet level at the time of venipuncture, said Dr. Hooper, so it’s hard to know what the platelet “dose” is from PRP.

After centrifuging, the sample will be stratified into a bottom portion, consisting primarily of red blood cells, a middle portion that’s the PRP, and a top portion that is platelet-poor plasma. Dr. Hooper draws up and saves the platelet- poor plasma as well, since it probably also contains some growth factors. She’ll save that for application or injection after a PRP treatment for some patients.

koakes@mdedge.com

SOURCE: Hooper, D. ODAC 2018.

ORLANDO – Platelet-rich plasma offers much for patients and dermatologists: It’s low-risk, has a low cost of entry, and usefully augments other medications and procedures for androgenetic alopecia and facial rejuvenation.

But there’s work to be done in standardizing its use and really understanding where, when, and for whom platelet-rich plasma (PRP) will be best used, said Dierdre Hooper, MD, a dermatologist in private practice in New Orleans.

As far back as the 1970s, PRP was used as a transfusion product, with use expanding during the following decade. “It’s really the ‘everywhere’ product,’” said Dr. Hooper, speaking at the Aesthetic, Surgical, and Clinical Dermatology Conference (ODAC).

Over the course of the past four decades, PRP has been explored for musculoskeletal healing, in gynecology, urology, cardiac surgery, ophthalmology, and for plastic surgery. “Initial skepticism has given way as some evidence is building,” said Dr. Hooper.

PRP, considered a biologic product, is produced by centrifuging a donor venipuncture. Among the pros of using PRP in a clinical practice, said Dr. Hooper, is the fact that numerous clinical studies do show benefit. The risk is low, as is the cost, and downtime is brief. All of these contribute to attractiveness to patients, who also like the idea of an all-natural product with an autologous source.

But consensus is lacking about some key aspects of utilization, including the best mode of preparation and optimal treatment schedule. Outcomes can be unpredictable, making it tough to say how cost-effective the regimen will be for a particular patient. “The ‘cons’ just come down to no consensus,” said Dr. Hooper.

Some of the basic science makes a compelling case for PRP: Activated platelets have secretory granules. These modify the pericellular milieu through release of a variety of growth factors by secretory granules. “We all were taught back in the day that platelets adhere to promote clotting, but they do a lot more than that – when the platelet is activated, it releases growth factors,” said Dr. Hooper. “Big picture? Think: This is how we heal.”

After blood collection, the sample is centrifuged. The goal of centrifuging is to achieve a platelet concentration of 1 to 1.5 million platelets per mL, or four to six times the platelet concentration seen in whole blood. In practice, there are variations in the mode of preparation, and in an individual’s platelet level at the time of venipuncture, said Dr. Hooper, so it’s hard to know what the platelet “dose” is from PRP.

After centrifuging, the sample will be stratified into a bottom portion, consisting primarily of red blood cells, a middle portion that’s the PRP, and a top portion that is platelet-poor plasma. Dr. Hooper draws up and saves the platelet- poor plasma as well, since it probably also contains some growth factors. She’ll save that for application or injection after a PRP treatment for some patients.

koakes@mdedge.com

SOURCE: Hooper, D. ODAC 2018.

ORLANDO – Platelet-rich plasma offers much for patients and dermatologists: It’s low-risk, has a low cost of entry, and usefully augments other medications and procedures for androgenetic alopecia and facial rejuvenation.

But there’s work to be done in standardizing its use and really understanding where, when, and for whom platelet-rich plasma (PRP) will be best used, said Dierdre Hooper, MD, a dermatologist in private practice in New Orleans.

As far back as the 1970s, PRP was used as a transfusion product, with use expanding during the following decade. “It’s really the ‘everywhere’ product,’” said Dr. Hooper, speaking at the Aesthetic, Surgical, and Clinical Dermatology Conference (ODAC).

Over the course of the past four decades, PRP has been explored for musculoskeletal healing, in gynecology, urology, cardiac surgery, ophthalmology, and for plastic surgery. “Initial skepticism has given way as some evidence is building,” said Dr. Hooper.

PRP, considered a biologic product, is produced by centrifuging a donor venipuncture. Among the pros of using PRP in a clinical practice, said Dr. Hooper, is the fact that numerous clinical studies do show benefit. The risk is low, as is the cost, and downtime is brief. All of these contribute to attractiveness to patients, who also like the idea of an all-natural product with an autologous source.

But consensus is lacking about some key aspects of utilization, including the best mode of preparation and optimal treatment schedule. Outcomes can be unpredictable, making it tough to say how cost-effective the regimen will be for a particular patient. “The ‘cons’ just come down to no consensus,” said Dr. Hooper.

Some of the basic science makes a compelling case for PRP: Activated platelets have secretory granules. These modify the pericellular milieu through release of a variety of growth factors by secretory granules. “We all were taught back in the day that platelets adhere to promote clotting, but they do a lot more than that – when the platelet is activated, it releases growth factors,” said Dr. Hooper. “Big picture? Think: This is how we heal.”

After blood collection, the sample is centrifuged. The goal of centrifuging is to achieve a platelet concentration of 1 to 1.5 million platelets per mL, or four to six times the platelet concentration seen in whole blood. In practice, there are variations in the mode of preparation, and in an individual’s platelet level at the time of venipuncture, said Dr. Hooper, so it’s hard to know what the platelet “dose” is from PRP.

After centrifuging, the sample will be stratified into a bottom portion, consisting primarily of red blood cells, a middle portion that’s the PRP, and a top portion that is platelet-poor plasma. Dr. Hooper draws up and saves the platelet- poor plasma as well, since it probably also contains some growth factors. She’ll save that for application or injection after a PRP treatment for some patients.

koakes@mdedge.com

SOURCE: Hooper, D. ODAC 2018.

Oral tranexamic acid (TA) proved to be an effective treatment for 50% of melasma sufferers, in a clinical trial of patients from a public dermatology clinic in Brazil.

“Our study was one of the few to compare the use of oral TA isolated against a control group using a placebo and to evaluate the results by four different methods,” wrote lead author Mariana Morais Tavares Colferai, MD, of the Universidade de Mogi das Cruzes (Brazil), and her coauthors. The study was published online in the Journal of Cosmetic Dermatology.TA is a plasmin inhibitor, first described as a treatment for melasma in 1979. It is approved in the United States for treating menorrhagia.

In the randomized, double-blind, controlled trial of 47 patients with facial melasma – 37 completed the study – participants were assigned to one of two groups: Group A received 250 mg of tranexamic acid twice daily (n = 20) while group B received a placebo twice daily (n = 17). All patients were advised to use sunscreen. Before treatment and after 12 weeks, the researchers evaluated patients with four methods: the Melasma Area Severity Index (MASI), photographic records, patient evaluation with questionnaire (MELASQoL), and colorimetry assessed via a colorimeter.


Per evaluation of all tests, melasma improved in 50% of patients in group A, compared with 5.9% of patients in group B (P less than .005). Group A saw improvements in the mean MASI score (20.9 at pretreatment vs. 10.8 after treatment, P less than .001), mean MELASQoL value (55.4 vs. 38.2, P less than .001), and colorimetry (55.0 vs. 56.1, with higher values indicating lighter pigmentation, P = .033).

The most common side effects among those who received TA were gastrointestinal effects, such as nausea and diarrhea (5%); changes in menstrual flow (10%); and headache (14%). No serious side effects were reported.

The authors acknowledged several potential limitations in their study, including a lack of intermediate evaluations between pretreatment and 12 weeks. They also noted that the photographs were dichotomously classified as either “yes for improvement” or “no for the lack of improvement or worsening,” which may “limit the accuracy of our results” for that particular method.

The tranexamic acid and placebo for the study was provided by U.SK Dermatology/Brazil. No conflicts of interest were reported.

SOURCE: Colferai MMT et al. J Cosmet Dermatol. 2018 Dec 9. doi: 10.1111/jocd.12830.

Oral tranexamic acid (TA) proved to be an effective treatment for 50% of melasma sufferers, in a clinical trial of patients from a public dermatology clinic in Brazil.

“Our study was one of the few to compare the use of oral TA isolated against a control group using a placebo and to evaluate the results by four different methods,” wrote lead author Mariana Morais Tavares Colferai, MD, of the Universidade de Mogi das Cruzes (Brazil), and her coauthors. The study was published online in the Journal of Cosmetic Dermatology.TA is a plasmin inhibitor, first described as a treatment for melasma in 1979. It is approved in the United States for treating menorrhagia.

In the randomized, double-blind, controlled trial of 47 patients with facial melasma – 37 completed the study – participants were assigned to one of two groups: Group A received 250 mg of tranexamic acid twice daily (n = 20) while group B received a placebo twice daily (n = 17). All patients were advised to use sunscreen. Before treatment and after 12 weeks, the researchers evaluated patients with four methods: the Melasma Area Severity Index (MASI), photographic records, patient evaluation with questionnaire (MELASQoL), and colorimetry assessed via a colorimeter.


Per evaluation of all tests, melasma improved in 50% of patients in group A, compared with 5.9% of patients in group B (P less than .005). Group A saw improvements in the mean MASI score (20.9 at pretreatment vs. 10.8 after treatment, P less than .001), mean MELASQoL value (55.4 vs. 38.2, P less than .001), and colorimetry (55.0 vs. 56.1, with higher values indicating lighter pigmentation, P = .033).

The most common side effects among those who received TA were gastrointestinal effects, such as nausea and diarrhea (5%); changes in menstrual flow (10%); and headache (14%). No serious side effects were reported.

The authors acknowledged several potential limitations in their study, including a lack of intermediate evaluations between pretreatment and 12 weeks. They also noted that the photographs were dichotomously classified as either “yes for improvement” or “no for the lack of improvement or worsening,” which may “limit the accuracy of our results” for that particular method.

The tranexamic acid and placebo for the study was provided by U.SK Dermatology/Brazil. No conflicts of interest were reported.

SOURCE: Colferai MMT et al. J Cosmet Dermatol. 2018 Dec 9. doi: 10.1111/jocd.12830.

Oral tranexamic acid (TA) proved to be an effective treatment for 50% of melasma sufferers, in a clinical trial of patients from a public dermatology clinic in Brazil.

“Our study was one of the few to compare the use of oral TA isolated against a control group using a placebo and to evaluate the results by four different methods,” wrote lead author Mariana Morais Tavares Colferai, MD, of the Universidade de Mogi das Cruzes (Brazil), and her coauthors. The study was published online in the Journal of Cosmetic Dermatology.TA is a plasmin inhibitor, first described as a treatment for melasma in 1979. It is approved in the United States for treating menorrhagia.

In the randomized, double-blind, controlled trial of 47 patients with facial melasma – 37 completed the study – participants were assigned to one of two groups: Group A received 250 mg of tranexamic acid twice daily (n = 20) while group B received a placebo twice daily (n = 17). All patients were advised to use sunscreen. Before treatment and after 12 weeks, the researchers evaluated patients with four methods: the Melasma Area Severity Index (MASI), photographic records, patient evaluation with questionnaire (MELASQoL), and colorimetry assessed via a colorimeter.


Per evaluation of all tests, melasma improved in 50% of patients in group A, compared with 5.9% of patients in group B (P less than .005). Group A saw improvements in the mean MASI score (20.9 at pretreatment vs. 10.8 after treatment, P less than .001), mean MELASQoL value (55.4 vs. 38.2, P less than .001), and colorimetry (55.0 vs. 56.1, with higher values indicating lighter pigmentation, P = .033).

The most common side effects among those who received TA were gastrointestinal effects, such as nausea and diarrhea (5%); changes in menstrual flow (10%); and headache (14%). No serious side effects were reported.

The authors acknowledged several potential limitations in their study, including a lack of intermediate evaluations between pretreatment and 12 weeks. They also noted that the photographs were dichotomously classified as either “yes for improvement” or “no for the lack of improvement or worsening,” which may “limit the accuracy of our results” for that particular method.

The tranexamic acid and placebo for the study was provided by U.SK Dermatology/Brazil. No conflicts of interest were reported.

SOURCE: Colferai MMT et al. J Cosmet Dermatol. 2018 Dec 9. doi: 10.1111/jocd.12830.

The topical retinoid tazarotene could be an efficacious and practical alternative to microneedling for treating atrophic postacne scarring, according to a new study.

In a prospective, randomized, split-face study of adults with postacne scarring, both treatments resulted in similar efficacy after 6 months, reported T.P. Afra, MD, and associates from the department of dermatology, venereology, and leprology at the Postgraduate Institute of Medical Education and Research in Chandigarh, India. While the clinical usefulness of microneedling as a procedure for postacne scarring is well established, research exploring the effectiveness of topical therapies for acne scarring that could be used at home is lacking. “A home-based topical treatment with a comparable efficacy to microneedling and that is well tolerated would be a useful addition in the armamentarium of acne scar management,” they wrote in the study, published in JAMA Facial Plastic Surgery.

The study included 34 patients, aged 18-30 years, with grade 2-4 facial atrophic acne scars at their initial visit to the research team’s skin clinic. One side of each participants face was randomized to receive microneedling treatment for four sessions over 3 months (using a dermaroller with 1.5-mm needles). Topical tazarotene gel 0.1%, a retinoid approved by the Food and Drug Administration as a treatment for mild to moderate facial acne, was applied to the other side of their face once a night during the same time. Almost 81% were skin phototypes IV, the rest were type III or V. Patients followed up every month for 3 months, then at 6 months.

Changes in acne scar severity from baseline, the primary outcome, were assessed using Goodman and Baron quantitative and qualitative scores and a subjective dermatologist score. Patient satisfaction measured with a Patient Global Assessment (PGA) score and adverse events were secondary outcomes.

In 31 patients (91.2%), overall improvements from baseline to the 6-month visit in quantitative acne scar severity scores for both treatments were seen, with significant improvements from baseline to 6 months: A median improvement of 3 on the sides of the face treated with microneedling and a median improvement of 2.5 on the sides of the face treated with tazarotene (between-group comparison, P = .42). The qualitative acne scar severity score did not significantly improve with either treatment, the investigators noted.

The median improvement in the independent dermatologist score was also comparable for both methods at 3 and 6 months.

At 6 months, improvement in the mean PGA score was “slightly but significantly superior” for the microneedling treatment, compared with that for tazarotene (mean of 5.86 vs. 5.76, respectively; P less than .001), with both falling into the “satisfactory” range for the PGA, the investigators wrote. They also noted a positive correlation between previous exposure to oral isotretinoin and patient satisfaction.

“Although collagen accumulation has been considered a drawback of isotretinoin therapy owing to the development of hypertrophic scars, the better atrophic acne scar outcomes observed for both the present treatment groups in patients with a history of isotretinoin treatment indicates that the collagen accumulation in this case may actually be beneficial,” they wrote.

The topical retinoid was well tolerated by participants, with less than a third reporting dryness and scaling, and adverse effects associated with microneedling were described as “minimal.”

“The use of a modality such as tazarotene that prevents acne flares while addressing acne scarring is a practical addition to clinical practice,” the investigators concluded. “Tazarotene gel 0.1% would be a useful alternative to microneedling in the management of atrophic acne scars. Such a home-based medical management option for acne scarring may decrease physician dependence and health care expenditures for patients with postacne scarring.”

The study authors noted that, as collagen remodeling is a continuous process lasting more than 1 year, a limitation of their study was its short-follow-up of 6 months. However, a strength of the study was its use of validated acne scar severity scoring tools as well as patient and physician assessment of scar improvement in the outcome assessments.

The authors had no disclosures to report.

SOURCE: Afra TP et al. JAMA Facial Plast Surg. 2018 Nov 15. doi: 10.1001/jamafacial.2018.1404.

The topical retinoid tazarotene could be an efficacious and practical alternative to microneedling for treating atrophic postacne scarring, according to a new study.

In a prospective, randomized, split-face study of adults with postacne scarring, both treatments resulted in similar efficacy after 6 months, reported T.P. Afra, MD, and associates from the department of dermatology, venereology, and leprology at the Postgraduate Institute of Medical Education and Research in Chandigarh, India. While the clinical usefulness of microneedling as a procedure for postacne scarring is well established, research exploring the effectiveness of topical therapies for acne scarring that could be used at home is lacking. “A home-based topical treatment with a comparable efficacy to microneedling and that is well tolerated would be a useful addition in the armamentarium of acne scar management,” they wrote in the study, published in JAMA Facial Plastic Surgery.

The study included 34 patients, aged 18-30 years, with grade 2-4 facial atrophic acne scars at their initial visit to the research team’s skin clinic. One side of each participants face was randomized to receive microneedling treatment for four sessions over 3 months (using a dermaroller with 1.5-mm needles). Topical tazarotene gel 0.1%, a retinoid approved by the Food and Drug Administration as a treatment for mild to moderate facial acne, was applied to the other side of their face once a night during the same time. Almost 81% were skin phototypes IV, the rest were type III or V. Patients followed up every month for 3 months, then at 6 months.

Changes in acne scar severity from baseline, the primary outcome, were assessed using Goodman and Baron quantitative and qualitative scores and a subjective dermatologist score. Patient satisfaction measured with a Patient Global Assessment (PGA) score and adverse events were secondary outcomes.

In 31 patients (91.2%), overall improvements from baseline to the 6-month visit in quantitative acne scar severity scores for both treatments were seen, with significant improvements from baseline to 6 months: A median improvement of 3 on the sides of the face treated with microneedling and a median improvement of 2.5 on the sides of the face treated with tazarotene (between-group comparison, P = .42). The qualitative acne scar severity score did not significantly improve with either treatment, the investigators noted.

The median improvement in the independent dermatologist score was also comparable for both methods at 3 and 6 months.

At 6 months, improvement in the mean PGA score was “slightly but significantly superior” for the microneedling treatment, compared with that for tazarotene (mean of 5.86 vs. 5.76, respectively; P less than .001), with both falling into the “satisfactory” range for the PGA, the investigators wrote. They also noted a positive correlation between previous exposure to oral isotretinoin and patient satisfaction.

“Although collagen accumulation has been considered a drawback of isotretinoin therapy owing to the development of hypertrophic scars, the better atrophic acne scar outcomes observed for both the present treatment groups in patients with a history of isotretinoin treatment indicates that the collagen accumulation in this case may actually be beneficial,” they wrote.

The topical retinoid was well tolerated by participants, with less than a third reporting dryness and scaling, and adverse effects associated with microneedling were described as “minimal.”

“The use of a modality such as tazarotene that prevents acne flares while addressing acne scarring is a practical addition to clinical practice,” the investigators concluded. “Tazarotene gel 0.1% would be a useful alternative to microneedling in the management of atrophic acne scars. Such a home-based medical management option for acne scarring may decrease physician dependence and health care expenditures for patients with postacne scarring.”

The study authors noted that, as collagen remodeling is a continuous process lasting more than 1 year, a limitation of their study was its short-follow-up of 6 months. However, a strength of the study was its use of validated acne scar severity scoring tools as well as patient and physician assessment of scar improvement in the outcome assessments.

The authors had no disclosures to report.

SOURCE: Afra TP et al. JAMA Facial Plast Surg. 2018 Nov 15. doi: 10.1001/jamafacial.2018.1404.

The topical retinoid tazarotene could be an efficacious and practical alternative to microneedling for treating atrophic postacne scarring, according to a new study.

In a prospective, randomized, split-face study of adults with postacne scarring, both treatments resulted in similar efficacy after 6 months, reported T.P. Afra, MD, and associates from the department of dermatology, venereology, and leprology at the Postgraduate Institute of Medical Education and Research in Chandigarh, India. While the clinical usefulness of microneedling as a procedure for postacne scarring is well established, research exploring the effectiveness of topical therapies for acne scarring that could be used at home is lacking. “A home-based topical treatment with a comparable efficacy to microneedling and that is well tolerated would be a useful addition in the armamentarium of acne scar management,” they wrote in the study, published in JAMA Facial Plastic Surgery.

The study included 34 patients, aged 18-30 years, with grade 2-4 facial atrophic acne scars at their initial visit to the research team’s skin clinic. One side of each participants face was randomized to receive microneedling treatment for four sessions over 3 months (using a dermaroller with 1.5-mm needles). Topical tazarotene gel 0.1%, a retinoid approved by the Food and Drug Administration as a treatment for mild to moderate facial acne, was applied to the other side of their face once a night during the same time. Almost 81% were skin phototypes IV, the rest were type III or V. Patients followed up every month for 3 months, then at 6 months.

Changes in acne scar severity from baseline, the primary outcome, were assessed using Goodman and Baron quantitative and qualitative scores and a subjective dermatologist score. Patient satisfaction measured with a Patient Global Assessment (PGA) score and adverse events were secondary outcomes.

In 31 patients (91.2%), overall improvements from baseline to the 6-month visit in quantitative acne scar severity scores for both treatments were seen, with significant improvements from baseline to 6 months: A median improvement of 3 on the sides of the face treated with microneedling and a median improvement of 2.5 on the sides of the face treated with tazarotene (between-group comparison, P = .42). The qualitative acne scar severity score did not significantly improve with either treatment, the investigators noted.

The median improvement in the independent dermatologist score was also comparable for both methods at 3 and 6 months.

At 6 months, improvement in the mean PGA score was “slightly but significantly superior” for the microneedling treatment, compared with that for tazarotene (mean of 5.86 vs. 5.76, respectively; P less than .001), with both falling into the “satisfactory” range for the PGA, the investigators wrote. They also noted a positive correlation between previous exposure to oral isotretinoin and patient satisfaction.

“Although collagen accumulation has been considered a drawback of isotretinoin therapy owing to the development of hypertrophic scars, the better atrophic acne scar outcomes observed for both the present treatment groups in patients with a history of isotretinoin treatment indicates that the collagen accumulation in this case may actually be beneficial,” they wrote.

The topical retinoid was well tolerated by participants, with less than a third reporting dryness and scaling, and adverse effects associated with microneedling were described as “minimal.”

“The use of a modality such as tazarotene that prevents acne flares while addressing acne scarring is a practical addition to clinical practice,” the investigators concluded. “Tazarotene gel 0.1% would be a useful alternative to microneedling in the management of atrophic acne scars. Such a home-based medical management option for acne scarring may decrease physician dependence and health care expenditures for patients with postacne scarring.”

The study authors noted that, as collagen remodeling is a continuous process lasting more than 1 year, a limitation of their study was its short-follow-up of 6 months. However, a strength of the study was its use of validated acne scar severity scoring tools as well as patient and physician assessment of scar improvement in the outcome assessments.

The authors had no disclosures to report.

SOURCE: Afra TP et al. JAMA Facial Plast Surg. 2018 Nov 15. doi: 10.1001/jamafacial.2018.1404.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

In October of this year, the first ever Integrative Dermatology Symposium was held in Sacramento, Calif., bringing together board-certified dermatologists, and practitioners of Ayurvedic, Naturopathic, and traditional Chinese medicine (TCM), in one place. This was the first time in the United States that practitioners from these different areas of medicine were brought together to discuss and learn different approaches to skin care and treatment of dermatologic diseases.

Daniel Schwen/CCA-SA 3.0

Of all the medical specialties, it is presumed that dermatology is the most inherently holistic. By examining the hair, skin, and nails, we are able to diagnose internal organ diseases such as liver failure (jaundice, veins on stomach), thyroid disease (madarosis), sarcoidosis, and infectious diseases (cutaneous manifestations of HIV), diabetes (acanthosis nigricans, tripe palm), polycystic ovary syndrome (acne, hirsutism), and porphyria, just to name a few. We are also able to treat cutaneous conditions, such as psoriasis, with biologic medications, treatment that in turn, also benefits internal manifestations such as joint, cardiovascular, and metabolic disease. In TCM and Ayurveda, the skin, hair, body type, and tongue can also be analyzed to diagnose and treat disease.

Salves and skin care routines that would be considered natural or holistic have been “prescribed” by Western dermatologists with an MD license for many years. Most medicines initially come from nature, and it is only in the past century, with the boom in the pharmaceutical industry and development of synthetic prescription medications, that people have forgotten this. Some of this boom has been needed to treat enormous populations, as natural resources can be scarce, and in some cases, only an extract of the plant may be needed for treatment, where other elements may be ineffective or even harmful.

Domeboro solution, Epsom salt soaks, and wet to dry soaks are used to draw out and treat infections. Bleach baths are often used to decrease bacterial load and calm inflammation when treating eczema. In Mohs surgery, Fredrick Mohs initially used a zinc chloride paste on nonmelanoma skin cancers in between stages, before frozen section processing and cosmetic reconstruction made Mohs what it is today. In the days of Hippocrates, food was medicine. If you were “red in the face” your blood was deemed too acidic and alkaline-forming foods or “cold foods” were given. This has now again come full circle with rosacea and evidence supporting a link between disease flares or improvement related to foods and the gut microbiome.

On a photography trip to Wyoming, I learned how Native Americans in the United States wiped the white powder from the bark of aspen trees on their skin and used it as sunscreen. In Mongolia, I learned how fat from a sheep’s bottom was used in beauty skin care routines. It is from native and nomadic people that we can often learn how effective natural methods can be used, especially in cases where the treatment regimens may not be written down. With Ayurveda and TCM, we are lucky that textbooks thousands of years old and professors and schools are available to educate us about these ancient practices.

The rediscovery of ancient treatments through the study of ethnobotany, Ayurveda, and TCM has been fascinating, as most of these approaches focus not just on the skin, but on treating the patient as a whole, inside and out (often depending on the discipline treating mind, body, and spirit), with the effects ultimately benefiting the skin. With the many advances in Western medicine over the past 2,000 years, starting with Hippocrates, it will be interesting to see how we, in the field of dermatology, can still learn from and potentially integrate medicine that originated 3,000-5,000 plus years ago in Ayurveda and 2,000-plus years ago in TCM that is still practiced today. In the future, we hope to have more columns about these specialties and how they are used in skin and beauty.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Wesley practices dermatology in Beverly Hills, Calif. Dr. Talakoub is in private practice in McLean, Va. This month’s column is by Dr. Wesley. Write to them at dermnews@mdedge.com. They had no relevant disclosures.

It may not seem intuitive, but to understand some of the new skin care claims, you need to know a bit about the gut microbiome and its role in skin health. The skin and gut host a copious and disparate array of bacteria, fungi, viruses, and mites. New research shows us that these microbes play an important role in skin health. The gut and skin play a balancing act between beneficial, neutral, and harmful flora that are interrelated with the innate and adaptive immune systems.¹ The skin and gut seem to be intertwined and express several comorbidities.² In this column, the focus is on the cutaneous microbiome’s role in skin health. To understand the cosmeceutical claims about pre- and probiotics, you first need to familiarize yourself with skin microbiome science. The skin-gut nexus will be discussed in next month’s column, which will address the role of the skin microbiome in skin diseases.

ChrisChrisW/Getty Images

Why is the microbiome such a hot topic?

Genetic sequencing has spurred advances in the study of the microbiome and has provided intriguing clues that the gut and skin microbiome have influences on each other. Sequencing assays that focus on bacterial 16S ribosomal RNA genes have been used by investigators to distinguish and describe the wide variety of resident and transient microorganisms on the skin and elucidate their roles in skin health and disease.¹ Genomic sequencing has identified species in the skin and gut that were not found previously by cultivating microbial isolates.^3,4 Advances in technologies such as whole-genome shotgun sequencing, metagenomics, and functional metabolomics will further contribute to our understanding of the effects of the skin microbiome on skin health and skin type. Of course, many supplement and cosmeceutical companies have jumped on this bandwagon prematurely and claim that their products increase “good bacteria while diminishing bad bacteria.” While there are interesting data that have emerged, we still cannot say which bacteria are “good” and ‘bad” as far as the skin is concerned – with a few exceptions that we have known all along. For example, Cutibacterium acnes and Staphylococcus aureus still remain in the undesirable category. (P. acnes has been renamed and now is officially referred to as C. acnes.) While it is premature to recommend probiotic– or prebiotic–containing cosmeceuticals, your patients will ask you about them. New studies about rosacea and the microbiome have generated a lot of patient questions in my practice, so I am writing several blogs about how to answer patient questions, which can be found at STSFranchise.com/blog. I’m also educating consumers on Facebook and Instagram @skintypesolutions so that they will not be taken advantage of by the too early “pseudoscience.” So now that you have heard that it is too early to recommend pre- and probiotic skin care to target skin issues, let’s look at the science that does exist.

Terminology

• Microbiome: Microbes that live in a particular environment or biome.
• Microbiota: The collection of living microbes that live in or on an environment. This term includes the microorganisms only and not the characteristics of their environment.
• Prebiotics: A nondigestible food ingredient that promotes the growth of microorganisms in the intestines. These can promote the growth of beneficial or harmful microorganisms. Think of them as a type of “fertilizer” for the microbiome.
• Probiotics: Living microorganisms that can provide beneficial qualities when used orally or topically. What probiotics are not? Microbes naturally found in your body and on your skin; microbes that are no longer alive; fermented foods that contain an unknown amount of bacteria.

Skin surface area

Richard Gallo, MD, a dermatologist from the University of California, San Diego, who is a leader in the microbiome field of study, says that estimates of the cutaneous microbiome’s impact on human health via skin have failed to acknowledge the inner follicular surface, thus drastically undervaluing the potential of the cutaneous microbiome to influence systemic health.⁵ He suggests that the surface area of skin has been miscalculated as measuring 2 m² because it is considered a flat surface. This ignores the plethora of hair follicles and sweat ducts that significantly broaden the epithelial surface to measure closer to 25 m² and underscores that the expansive skin microbiome is much larger than previously recognized.⁵ Taking the hair follicle surface area into account, the skin has vast space to harbor various organisms and microbiome environments. What our patients use on their skin certainly influences these environments. The key is trying to figure out how to manipulate the microbiome to our patient’s advantage.

Microbes have environmental preferences

Different microbial species thrive on particular regions of the diverse topography of the expansive surface area and choose their preferred environments from among sebaceous or nonsebaceous, hairy or smooth, moist or dry, and creased or noncreased areas.^6,7 Other host factors that affect which microorganisms colonize the skin include hair follicle thickness, age, sex, diet (especially high fat and sugar intake), climate, occupation, and personal hygiene.^7-10 Gene sequencing has revealed that these variations are partially because of factors such as ultraviolet exposure, pH, and temperature.^4,6,11 For example, C. acnes has been found to be more prevalent in highly sebaceous sites on the head and upper torso.⁴ In general, Propionibacteriaceae (Cutibacterium) prefer sebaceous areas, whereas Corynebacteriaceae and Staphylococcaceae prevail in moist regions, such as the navel or axilla. Dry areas host the widest diversity of microbes, including Corynebacterium, Staphylococcus, and Streptococcus species.^1,7,12

Impact of sebum and skin hydration on microbiome

In 2016, Mukherjee et al. measured sebum and hydration from the forehead and cheeks of 30 healthy female volunteers in a study that tested the hypothesis that differences in sebum and hydration levels in specific facial areas account for interindividual variation in facial skin microbiome. They found that the most significant predictor of microbiome composition was cheek sebum level, followed by forehead hydration level, while cheek hydration and forehead sebum levels were not predictive. The prevalence of Actinobacteria/Propionibacterium rose, while microbiome diversity diminished with an increase in cheek sebum, with such trends reversed in relation to forehead hydration. The investigators concluded that site-specific sebum and water levels impact the nature and diversity of the facial skin microbiome.¹³

Lability of the cutaneous microbiome

The skin microbiome changes during various times of life. For example, in puberty, more lipophilic species such as Propionibacteriaceae and Cornebacteriaceae predominate, while prior to puberty there is a preponderance of Firmicutes, Bacteroidetes, and Proteobacteria.^4,14 However, in the absence of lifestyle changes, cutaneous microbial communities have been found through longitudinal studies to be relatively stable over a 2-year period.⁶ A person’s skin microbiome is subject to influence from an adjacent skin microbiome, such as between cohabiting couples or the influence of breastfeeding mothers.¹⁵ It is never too early to consider the role of the microbiome in health and disease. For example, infant microbiomes play a role in eczema and the atopic march.¹⁶ For this reason, those of us who treat children need to be familiar with studies that have demonstrate how the cutaneous microbiome is affected by childbirth delivery method, breastfeeding, the mother’s diet antibiotic use during pregnancy and breastfeeding.^4,17

Microbiome effects on skin function

The skin barrier, a bilayer lipid-laden membrane that surrounds keratinocytes and prevents transepidermal water loss, is affected by resident microbial communities and has been shown by research to be influenced by the volume and diversity of such microbes.¹⁸ Organisms on the skin’s surface play an important role in communicating with and educating the cutaneous arm of the immune system.¹⁹ In 2017, Maguire and Maguire reviewed recent studies of the gut and skin microbiomes and suggested that Nitrobacter, Lactobacillus, and Bifidobacterium can improve skin health and could be useful bacterial adjuvants in a probiotic and prebiotic strategy in homeostatic renormalization when skin health is compromised.²⁰Nitrobacter has displayed antifungal activity against dermatophytes and Staphylococcus; Lactobacillus has exhibited anti-inflammatory effects and was shown to improve adult acne in a small study; Bifidobacterium combined with Lactobacillus lowered the incidence of atopic eczema in early childhood; and Bifidobacterium and the prebiotic galacto-oligosaccharide prevented hydration level losses in the stratum corneum among other beneficial effects in a double-blind, placebo-controlled, randomized trial.²⁰

Microbiome diversity is key

Microbes interact, collaborate, and oppose one another while exerting influence and being affected by the host. Effective communication among the innate and adaptive parts of the immune system, epithelial cells, and cutaneous microbiota is essential for optimal functioning of the skin.^6,7 Studies on subjects with atopic dermatitis showed a strong association between decreased diversity and increased disease severity. This suggests that a diverse microbiome is associated with skin health.²¹ For this reason, use of pre- and probiotics for skin issues is discouraged at this time. If we replace the normal diverse flora with one organism, we do not yet know the consequences. It is much more likely that successful treatments in the future will contain a diverse group of organisms.

Cosmeceutical effects on the skin microbiome

Cleansing and use of emollients certainly affect the skin biome, but we do not yet know to what extent. A study that looked at the effects of emollients on infants with atopic dermatitis showed that the emollient group has a lower skin pH and a more diverse microbiome.²² In a 2016 study on the impact of acute treatment with topical skin cleansers on the cutaneous microbiome, investigators evaluated multiple common skin cleansers in the washing of human forearms. Group A Streptococcus growth was reduced after washing with soaps infused with such antimicrobial compounds as benzalkonium chloride or triclocarban. The researchers stipulated that much more research is necessary to ascertain the effects of chronic washing as well as the that role skin care products may play in skin homeostasis or dysbiosis in some individuals.²³

In a 2017 analysis of the effects of cosmetics on the skin microbiome of facial cheeks with high- and low-hydration levels over 4 weeks, Lee et al. found that bacterial diversity was higher in the low-hydration group, with increases in both observed after the use of cosmetics. The high-hydration group showed a greater supply of Propionibacterium. Cosmetic use was found not to have caused a shift in bacterial communities in the low-hydration group.²⁴

Conclusion

We are in the early stages as we strive to learn more about the microbiome to leverage such knowledge to improve skin health. In the meantime, there is not enough evidence to suggest the use of any oral or topical prebiotics or probiotics to improve skin health. In fact, we may be causing harm by lessening diversity. The New York Times recently published an article called “The Problem with Probiotics” that referenced a JAMA Internal Medicine article entitled “Probiotic Safety – No Guarantees.”²⁵ I recommend that you read those. Next month, I will look more closely at microbiome research pertaining to skin disease.
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. Dréno B et al. J Eur Acad Dermatol Venereol. 2016 Dec;30(12):2038-47.

2. O’Neill CA et al. Bioessays. 2016 Nov;38(11):1167-76.

3. Kong HH. Trends Mol Med. 2011 Jun;17(6):320-8.

4. Kong HH et al. J Invest Dermatol. 2017 May;137(5):e119-22.

5. Gallo RL. J Invest Dermatol. 2017 Jun;137(6):1213-4.

6. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

7. Grice EA et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.

8. Rodrigues Hoffmann A. Vet Dermatol. 2017 Feb;28(1):60-e15.

9. Moestrup KS et al. J Invest Dermatol. 2018 May;138(5):1225-8.

10. Prescott SL et al. World Allergy Organ J. 2017 Aug 22;10(1):29.

11. Costello EK et al. Science. 2009 Dec 18;326(5960):1694-7.

12. Zeeuwen PL et al. Genome Biol. 2012 Nov 15;13(11):R101.

13. Mukherjee S et al. Sci Rep. 2016 Oct 27;6:36062.

14. Oh J et al. Genome Med. 2012 Oct 10;4(10):77.

15. Ross AA et al. mSystems. 2017 Jul 20;2(4).

16. Blázquez AB et al. Transl Res. 2017 Jan;179:199-203.

17. Rock R et al. Open Forum Infect Dis. 2017 Oct;4(1):S232.

18. Baldwin HE et al. J Drugs Dermatol. 2017 Jan 1;16(1):12-8.

19. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

20. Maguire M et al. Arch Dermatol Res. 2017 Aug;309(6):411-21.

21. Kong HH et al. Genome Res. 2012 May;22(5):850-9.

22. Glatz M et al. PLoS One. 2018 Feb 28;13(2):e0192443.

23. Two AM et al. J Invest Dermatol. 2016 Oct;136(10):1950-4.

24. Lee HJ et al. MicrobiologyOpen. 2018 Apr;7(2):e00557. doi: 10.1002/mbo3.557.

25. Cohen PA. JAMA Intern Med. 2018 Sep 17. doi: 10.1001/jamainternmed.2018.5403.






 

It may not seem intuitive, but to understand some of the new skin care claims, you need to know a bit about the gut microbiome and its role in skin health. The skin and gut host a copious and disparate array of bacteria, fungi, viruses, and mites. New research shows us that these microbes play an important role in skin health. The gut and skin play a balancing act between beneficial, neutral, and harmful flora that are interrelated with the innate and adaptive immune systems.¹ The skin and gut seem to be intertwined and express several comorbidities.² In this column, the focus is on the cutaneous microbiome’s role in skin health. To understand the cosmeceutical claims about pre- and probiotics, you first need to familiarize yourself with skin microbiome science. The skin-gut nexus will be discussed in next month’s column, which will address the role of the skin microbiome in skin diseases.

ChrisChrisW/Getty Images

Why is the microbiome such a hot topic?

Genetic sequencing has spurred advances in the study of the microbiome and has provided intriguing clues that the gut and skin microbiome have influences on each other. Sequencing assays that focus on bacterial 16S ribosomal RNA genes have been used by investigators to distinguish and describe the wide variety of resident and transient microorganisms on the skin and elucidate their roles in skin health and disease.¹ Genomic sequencing has identified species in the skin and gut that were not found previously by cultivating microbial isolates.^3,4 Advances in technologies such as whole-genome shotgun sequencing, metagenomics, and functional metabolomics will further contribute to our understanding of the effects of the skin microbiome on skin health and skin type. Of course, many supplement and cosmeceutical companies have jumped on this bandwagon prematurely and claim that their products increase “good bacteria while diminishing bad bacteria.” While there are interesting data that have emerged, we still cannot say which bacteria are “good” and ‘bad” as far as the skin is concerned – with a few exceptions that we have known all along. For example, Cutibacterium acnes and Staphylococcus aureus still remain in the undesirable category. (P. acnes has been renamed and now is officially referred to as C. acnes.) While it is premature to recommend probiotic– or prebiotic–containing cosmeceuticals, your patients will ask you about them. New studies about rosacea and the microbiome have generated a lot of patient questions in my practice, so I am writing several blogs about how to answer patient questions, which can be found at STSFranchise.com/blog. I’m also educating consumers on Facebook and Instagram @skintypesolutions so that they will not be taken advantage of by the too early “pseudoscience.” So now that you have heard that it is too early to recommend pre- and probiotic skin care to target skin issues, let’s look at the science that does exist.

Terminology

• Microbiome: Microbes that live in a particular environment or biome.
• Microbiota: The collection of living microbes that live in or on an environment. This term includes the microorganisms only and not the characteristics of their environment.
• Prebiotics: A nondigestible food ingredient that promotes the growth of microorganisms in the intestines. These can promote the growth of beneficial or harmful microorganisms. Think of them as a type of “fertilizer” for the microbiome.
• Probiotics: Living microorganisms that can provide beneficial qualities when used orally or topically. What probiotics are not? Microbes naturally found in your body and on your skin; microbes that are no longer alive; fermented foods that contain an unknown amount of bacteria.

Skin surface area

Richard Gallo, MD, a dermatologist from the University of California, San Diego, who is a leader in the microbiome field of study, says that estimates of the cutaneous microbiome’s impact on human health via skin have failed to acknowledge the inner follicular surface, thus drastically undervaluing the potential of the cutaneous microbiome to influence systemic health.⁵ He suggests that the surface area of skin has been miscalculated as measuring 2 m² because it is considered a flat surface. This ignores the plethora of hair follicles and sweat ducts that significantly broaden the epithelial surface to measure closer to 25 m² and underscores that the expansive skin microbiome is much larger than previously recognized.⁵ Taking the hair follicle surface area into account, the skin has vast space to harbor various organisms and microbiome environments. What our patients use on their skin certainly influences these environments. The key is trying to figure out how to manipulate the microbiome to our patient’s advantage.

Microbes have environmental preferences

Different microbial species thrive on particular regions of the diverse topography of the expansive surface area and choose their preferred environments from among sebaceous or nonsebaceous, hairy or smooth, moist or dry, and creased or noncreased areas.^6,7 Other host factors that affect which microorganisms colonize the skin include hair follicle thickness, age, sex, diet (especially high fat and sugar intake), climate, occupation, and personal hygiene.^7-10 Gene sequencing has revealed that these variations are partially because of factors such as ultraviolet exposure, pH, and temperature.^4,6,11 For example, C. acnes has been found to be more prevalent in highly sebaceous sites on the head and upper torso.⁴ In general, Propionibacteriaceae (Cutibacterium) prefer sebaceous areas, whereas Corynebacteriaceae and Staphylococcaceae prevail in moist regions, such as the navel or axilla. Dry areas host the widest diversity of microbes, including Corynebacterium, Staphylococcus, and Streptococcus species.^1,7,12

Impact of sebum and skin hydration on microbiome

In 2016, Mukherjee et al. measured sebum and hydration from the forehead and cheeks of 30 healthy female volunteers in a study that tested the hypothesis that differences in sebum and hydration levels in specific facial areas account for interindividual variation in facial skin microbiome. They found that the most significant predictor of microbiome composition was cheek sebum level, followed by forehead hydration level, while cheek hydration and forehead sebum levels were not predictive. The prevalence of Actinobacteria/Propionibacterium rose, while microbiome diversity diminished with an increase in cheek sebum, with such trends reversed in relation to forehead hydration. The investigators concluded that site-specific sebum and water levels impact the nature and diversity of the facial skin microbiome.¹³

Lability of the cutaneous microbiome

The skin microbiome changes during various times of life. For example, in puberty, more lipophilic species such as Propionibacteriaceae and Cornebacteriaceae predominate, while prior to puberty there is a preponderance of Firmicutes, Bacteroidetes, and Proteobacteria.^4,14 However, in the absence of lifestyle changes, cutaneous microbial communities have been found through longitudinal studies to be relatively stable over a 2-year period.⁶ A person’s skin microbiome is subject to influence from an adjacent skin microbiome, such as between cohabiting couples or the influence of breastfeeding mothers.¹⁵ It is never too early to consider the role of the microbiome in health and disease. For example, infant microbiomes play a role in eczema and the atopic march.¹⁶ For this reason, those of us who treat children need to be familiar with studies that have demonstrate how the cutaneous microbiome is affected by childbirth delivery method, breastfeeding, the mother’s diet antibiotic use during pregnancy and breastfeeding.^4,17

Microbiome effects on skin function

The skin barrier, a bilayer lipid-laden membrane that surrounds keratinocytes and prevents transepidermal water loss, is affected by resident microbial communities and has been shown by research to be influenced by the volume and diversity of such microbes.¹⁸ Organisms on the skin’s surface play an important role in communicating with and educating the cutaneous arm of the immune system.¹⁹ In 2017, Maguire and Maguire reviewed recent studies of the gut and skin microbiomes and suggested that Nitrobacter, Lactobacillus, and Bifidobacterium can improve skin health and could be useful bacterial adjuvants in a probiotic and prebiotic strategy in homeostatic renormalization when skin health is compromised.²⁰Nitrobacter has displayed antifungal activity against dermatophytes and Staphylococcus; Lactobacillus has exhibited anti-inflammatory effects and was shown to improve adult acne in a small study; Bifidobacterium combined with Lactobacillus lowered the incidence of atopic eczema in early childhood; and Bifidobacterium and the prebiotic galacto-oligosaccharide prevented hydration level losses in the stratum corneum among other beneficial effects in a double-blind, placebo-controlled, randomized trial.²⁰

Microbiome diversity is key

Microbes interact, collaborate, and oppose one another while exerting influence and being affected by the host. Effective communication among the innate and adaptive parts of the immune system, epithelial cells, and cutaneous microbiota is essential for optimal functioning of the skin.^6,7 Studies on subjects with atopic dermatitis showed a strong association between decreased diversity and increased disease severity. This suggests that a diverse microbiome is associated with skin health.²¹ For this reason, use of pre- and probiotics for skin issues is discouraged at this time. If we replace the normal diverse flora with one organism, we do not yet know the consequences. It is much more likely that successful treatments in the future will contain a diverse group of organisms.

Cosmeceutical effects on the skin microbiome

Cleansing and use of emollients certainly affect the skin biome, but we do not yet know to what extent. A study that looked at the effects of emollients on infants with atopic dermatitis showed that the emollient group has a lower skin pH and a more diverse microbiome.²² In a 2016 study on the impact of acute treatment with topical skin cleansers on the cutaneous microbiome, investigators evaluated multiple common skin cleansers in the washing of human forearms. Group A Streptococcus growth was reduced after washing with soaps infused with such antimicrobial compounds as benzalkonium chloride or triclocarban. The researchers stipulated that much more research is necessary to ascertain the effects of chronic washing as well as the that role skin care products may play in skin homeostasis or dysbiosis in some individuals.²³

In a 2017 analysis of the effects of cosmetics on the skin microbiome of facial cheeks with high- and low-hydration levels over 4 weeks, Lee et al. found that bacterial diversity was higher in the low-hydration group, with increases in both observed after the use of cosmetics. The high-hydration group showed a greater supply of Propionibacterium. Cosmetic use was found not to have caused a shift in bacterial communities in the low-hydration group.²⁴

Conclusion

We are in the early stages as we strive to learn more about the microbiome to leverage such knowledge to improve skin health. In the meantime, there is not enough evidence to suggest the use of any oral or topical prebiotics or probiotics to improve skin health. In fact, we may be causing harm by lessening diversity. The New York Times recently published an article called “The Problem with Probiotics” that referenced a JAMA Internal Medicine article entitled “Probiotic Safety – No Guarantees.”²⁵ I recommend that you read those. Next month, I will look more closely at microbiome research pertaining to skin disease.
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. Dréno B et al. J Eur Acad Dermatol Venereol. 2016 Dec;30(12):2038-47.

2. O’Neill CA et al. Bioessays. 2016 Nov;38(11):1167-76.

3. Kong HH. Trends Mol Med. 2011 Jun;17(6):320-8.

4. Kong HH et al. J Invest Dermatol. 2017 May;137(5):e119-22.

5. Gallo RL. J Invest Dermatol. 2017 Jun;137(6):1213-4.

6. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

7. Grice EA et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.

8. Rodrigues Hoffmann A. Vet Dermatol. 2017 Feb;28(1):60-e15.

9. Moestrup KS et al. J Invest Dermatol. 2018 May;138(5):1225-8.

10. Prescott SL et al. World Allergy Organ J. 2017 Aug 22;10(1):29.

11. Costello EK et al. Science. 2009 Dec 18;326(5960):1694-7.

12. Zeeuwen PL et al. Genome Biol. 2012 Nov 15;13(11):R101.

13. Mukherjee S et al. Sci Rep. 2016 Oct 27;6:36062.

14. Oh J et al. Genome Med. 2012 Oct 10;4(10):77.

15. Ross AA et al. mSystems. 2017 Jul 20;2(4).

16. Blázquez AB et al. Transl Res. 2017 Jan;179:199-203.

17. Rock R et al. Open Forum Infect Dis. 2017 Oct;4(1):S232.

18. Baldwin HE et al. J Drugs Dermatol. 2017 Jan 1;16(1):12-8.

19. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

20. Maguire M et al. Arch Dermatol Res. 2017 Aug;309(6):411-21.

21. Kong HH et al. Genome Res. 2012 May;22(5):850-9.

22. Glatz M et al. PLoS One. 2018 Feb 28;13(2):e0192443.

23. Two AM et al. J Invest Dermatol. 2016 Oct;136(10):1950-4.

24. Lee HJ et al. MicrobiologyOpen. 2018 Apr;7(2):e00557. doi: 10.1002/mbo3.557.

25. Cohen PA. JAMA Intern Med. 2018 Sep 17. doi: 10.1001/jamainternmed.2018.5403.






 

It may not seem intuitive, but to understand some of the new skin care claims, you need to know a bit about the gut microbiome and its role in skin health. The skin and gut host a copious and disparate array of bacteria, fungi, viruses, and mites. New research shows us that these microbes play an important role in skin health. The gut and skin play a balancing act between beneficial, neutral, and harmful flora that are interrelated with the innate and adaptive immune systems.¹ The skin and gut seem to be intertwined and express several comorbidities.² In this column, the focus is on the cutaneous microbiome’s role in skin health. To understand the cosmeceutical claims about pre- and probiotics, you first need to familiarize yourself with skin microbiome science. The skin-gut nexus will be discussed in next month’s column, which will address the role of the skin microbiome in skin diseases.

ChrisChrisW/Getty Images

Why is the microbiome such a hot topic?

Genetic sequencing has spurred advances in the study of the microbiome and has provided intriguing clues that the gut and skin microbiome have influences on each other. Sequencing assays that focus on bacterial 16S ribosomal RNA genes have been used by investigators to distinguish and describe the wide variety of resident and transient microorganisms on the skin and elucidate their roles in skin health and disease.¹ Genomic sequencing has identified species in the skin and gut that were not found previously by cultivating microbial isolates.^3,4 Advances in technologies such as whole-genome shotgun sequencing, metagenomics, and functional metabolomics will further contribute to our understanding of the effects of the skin microbiome on skin health and skin type. Of course, many supplement and cosmeceutical companies have jumped on this bandwagon prematurely and claim that their products increase “good bacteria while diminishing bad bacteria.” While there are interesting data that have emerged, we still cannot say which bacteria are “good” and ‘bad” as far as the skin is concerned – with a few exceptions that we have known all along. For example, Cutibacterium acnes and Staphylococcus aureus still remain in the undesirable category. (P. acnes has been renamed and now is officially referred to as C. acnes.) While it is premature to recommend probiotic– or prebiotic–containing cosmeceuticals, your patients will ask you about them. New studies about rosacea and the microbiome have generated a lot of patient questions in my practice, so I am writing several blogs about how to answer patient questions, which can be found at STSFranchise.com/blog. I’m also educating consumers on Facebook and Instagram @skintypesolutions so that they will not be taken advantage of by the too early “pseudoscience.” So now that you have heard that it is too early to recommend pre- and probiotic skin care to target skin issues, let’s look at the science that does exist.

Terminology

• Microbiome: Microbes that live in a particular environment or biome.
• Microbiota: The collection of living microbes that live in or on an environment. This term includes the microorganisms only and not the characteristics of their environment.
• Prebiotics: A nondigestible food ingredient that promotes the growth of microorganisms in the intestines. These can promote the growth of beneficial or harmful microorganisms. Think of them as a type of “fertilizer” for the microbiome.
• Probiotics: Living microorganisms that can provide beneficial qualities when used orally or topically. What probiotics are not? Microbes naturally found in your body and on your skin; microbes that are no longer alive; fermented foods that contain an unknown amount of bacteria.

Skin surface area

Richard Gallo, MD, a dermatologist from the University of California, San Diego, who is a leader in the microbiome field of study, says that estimates of the cutaneous microbiome’s impact on human health via skin have failed to acknowledge the inner follicular surface, thus drastically undervaluing the potential of the cutaneous microbiome to influence systemic health.⁵ He suggests that the surface area of skin has been miscalculated as measuring 2 m² because it is considered a flat surface. This ignores the plethora of hair follicles and sweat ducts that significantly broaden the epithelial surface to measure closer to 25 m² and underscores that the expansive skin microbiome is much larger than previously recognized.⁵ Taking the hair follicle surface area into account, the skin has vast space to harbor various organisms and microbiome environments. What our patients use on their skin certainly influences these environments. The key is trying to figure out how to manipulate the microbiome to our patient’s advantage.

Microbes have environmental preferences

Different microbial species thrive on particular regions of the diverse topography of the expansive surface area and choose their preferred environments from among sebaceous or nonsebaceous, hairy or smooth, moist or dry, and creased or noncreased areas.^6,7 Other host factors that affect which microorganisms colonize the skin include hair follicle thickness, age, sex, diet (especially high fat and sugar intake), climate, occupation, and personal hygiene.^7-10 Gene sequencing has revealed that these variations are partially because of factors such as ultraviolet exposure, pH, and temperature.^4,6,11 For example, C. acnes has been found to be more prevalent in highly sebaceous sites on the head and upper torso.⁴ In general, Propionibacteriaceae (Cutibacterium) prefer sebaceous areas, whereas Corynebacteriaceae and Staphylococcaceae prevail in moist regions, such as the navel or axilla. Dry areas host the widest diversity of microbes, including Corynebacterium, Staphylococcus, and Streptococcus species.^1,7,12

Impact of sebum and skin hydration on microbiome

In 2016, Mukherjee et al. measured sebum and hydration from the forehead and cheeks of 30 healthy female volunteers in a study that tested the hypothesis that differences in sebum and hydration levels in specific facial areas account for interindividual variation in facial skin microbiome. They found that the most significant predictor of microbiome composition was cheek sebum level, followed by forehead hydration level, while cheek hydration and forehead sebum levels were not predictive. The prevalence of Actinobacteria/Propionibacterium rose, while microbiome diversity diminished with an increase in cheek sebum, with such trends reversed in relation to forehead hydration. The investigators concluded that site-specific sebum and water levels impact the nature and diversity of the facial skin microbiome.¹³

Lability of the cutaneous microbiome

The skin microbiome changes during various times of life. For example, in puberty, more lipophilic species such as Propionibacteriaceae and Cornebacteriaceae predominate, while prior to puberty there is a preponderance of Firmicutes, Bacteroidetes, and Proteobacteria.^4,14 However, in the absence of lifestyle changes, cutaneous microbial communities have been found through longitudinal studies to be relatively stable over a 2-year period.⁶ A person’s skin microbiome is subject to influence from an adjacent skin microbiome, such as between cohabiting couples or the influence of breastfeeding mothers.¹⁵ It is never too early to consider the role of the microbiome in health and disease. For example, infant microbiomes play a role in eczema and the atopic march.¹⁶ For this reason, those of us who treat children need to be familiar with studies that have demonstrate how the cutaneous microbiome is affected by childbirth delivery method, breastfeeding, the mother’s diet antibiotic use during pregnancy and breastfeeding.^4,17

Microbiome effects on skin function

The skin barrier, a bilayer lipid-laden membrane that surrounds keratinocytes and prevents transepidermal water loss, is affected by resident microbial communities and has been shown by research to be influenced by the volume and diversity of such microbes.¹⁸ Organisms on the skin’s surface play an important role in communicating with and educating the cutaneous arm of the immune system.¹⁹ In 2017, Maguire and Maguire reviewed recent studies of the gut and skin microbiomes and suggested that Nitrobacter, Lactobacillus, and Bifidobacterium can improve skin health and could be useful bacterial adjuvants in a probiotic and prebiotic strategy in homeostatic renormalization when skin health is compromised.²⁰Nitrobacter has displayed antifungal activity against dermatophytes and Staphylococcus; Lactobacillus has exhibited anti-inflammatory effects and was shown to improve adult acne in a small study; Bifidobacterium combined with Lactobacillus lowered the incidence of atopic eczema in early childhood; and Bifidobacterium and the prebiotic galacto-oligosaccharide prevented hydration level losses in the stratum corneum among other beneficial effects in a double-blind, placebo-controlled, randomized trial.²⁰

Microbiome diversity is key

Microbes interact, collaborate, and oppose one another while exerting influence and being affected by the host. Effective communication among the innate and adaptive parts of the immune system, epithelial cells, and cutaneous microbiota is essential for optimal functioning of the skin.^6,7 Studies on subjects with atopic dermatitis showed a strong association between decreased diversity and increased disease severity. This suggests that a diverse microbiome is associated with skin health.²¹ For this reason, use of pre- and probiotics for skin issues is discouraged at this time. If we replace the normal diverse flora with one organism, we do not yet know the consequences. It is much more likely that successful treatments in the future will contain a diverse group of organisms.

Cosmeceutical effects on the skin microbiome

Cleansing and use of emollients certainly affect the skin biome, but we do not yet know to what extent. A study that looked at the effects of emollients on infants with atopic dermatitis showed that the emollient group has a lower skin pH and a more diverse microbiome.²² In a 2016 study on the impact of acute treatment with topical skin cleansers on the cutaneous microbiome, investigators evaluated multiple common skin cleansers in the washing of human forearms. Group A Streptococcus growth was reduced after washing with soaps infused with such antimicrobial compounds as benzalkonium chloride or triclocarban. The researchers stipulated that much more research is necessary to ascertain the effects of chronic washing as well as the that role skin care products may play in skin homeostasis or dysbiosis in some individuals.²³

In a 2017 analysis of the effects of cosmetics on the skin microbiome of facial cheeks with high- and low-hydration levels over 4 weeks, Lee et al. found that bacterial diversity was higher in the low-hydration group, with increases in both observed after the use of cosmetics. The high-hydration group showed a greater supply of Propionibacterium. Cosmetic use was found not to have caused a shift in bacterial communities in the low-hydration group.²⁴

Conclusion

We are in the early stages as we strive to learn more about the microbiome to leverage such knowledge to improve skin health. In the meantime, there is not enough evidence to suggest the use of any oral or topical prebiotics or probiotics to improve skin health. In fact, we may be causing harm by lessening diversity. The New York Times recently published an article called “The Problem with Probiotics” that referenced a JAMA Internal Medicine article entitled “Probiotic Safety – No Guarantees.”²⁵ I recommend that you read those. Next month, I will look more closely at microbiome research pertaining to skin disease.
 

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC.

References

1. Dréno B et al. J Eur Acad Dermatol Venereol. 2016 Dec;30(12):2038-47.

2. O’Neill CA et al. Bioessays. 2016 Nov;38(11):1167-76.

3. Kong HH. Trends Mol Med. 2011 Jun;17(6):320-8.

4. Kong HH et al. J Invest Dermatol. 2017 May;137(5):e119-22.

5. Gallo RL. J Invest Dermatol. 2017 Jun;137(6):1213-4.

6. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

7. Grice EA et al. Nat Rev Microbiol. 2011 Apr;9(4):244-53.

8. Rodrigues Hoffmann A. Vet Dermatol. 2017 Feb;28(1):60-e15.

9. Moestrup KS et al. J Invest Dermatol. 2018 May;138(5):1225-8.

10. Prescott SL et al. World Allergy Organ J. 2017 Aug 22;10(1):29.

11. Costello EK et al. Science. 2009 Dec 18;326(5960):1694-7.

12. Zeeuwen PL et al. Genome Biol. 2012 Nov 15;13(11):R101.

13. Mukherjee S et al. Sci Rep. 2016 Oct 27;6:36062.

14. Oh J et al. Genome Med. 2012 Oct 10;4(10):77.

15. Ross AA et al. mSystems. 2017 Jul 20;2(4).

16. Blázquez AB et al. Transl Res. 2017 Jan;179:199-203.

17. Rock R et al. Open Forum Infect Dis. 2017 Oct;4(1):S232.

18. Baldwin HE et al. J Drugs Dermatol. 2017 Jan 1;16(1):12-8.

19. Byrd AL et al. Nat Rev Microbiol. 2018 Mar;16(3):143-55.

20. Maguire M et al. Arch Dermatol Res. 2017 Aug;309(6):411-21.

21. Kong HH et al. Genome Res. 2012 May;22(5):850-9.

22. Glatz M et al. PLoS One. 2018 Feb 28;13(2):e0192443.

23. Two AM et al. J Invest Dermatol. 2016 Oct;136(10):1950-4.

24. Lee HJ et al. MicrobiologyOpen. 2018 Apr;7(2):e00557. doi: 10.1002/mbo3.557.

25. Cohen PA. JAMA Intern Med. 2018 Sep 17. doi: 10.1001/jamainternmed.2018.5403.






 

Performing facial muscle exercises after botulinum toxin injections to the forehead speeds up the clinical effects of the injections by 1 day, a small, randomized study has shown.

The study addressed the lack of data regarding whether exercising treated muscles for several hours after injections helped “to enhance uptake” of botulinum toxin, said Murad Alam, MD, chief of cutaneous and aesthetic surgery and a professor of dermatology at Northwestern University, Chicago, and his coauthors.

“The results of this study suggest that a postinjection facial exercise regimen is a safe and effective method for achieving an earlier onset of clinical effect of botulinum toxin injections,” he and his coauthors concluded. The results were reported in the Journal of the American Academy of Dermatology.

The study enrolled 22 women, aged 27-66 years (mean age, 47 years) who received botulinum toxin injections for forehead and glabella dynamic rhytids. Following the injections, half of the women did the exercises for 4 hours and the other half avoided facial contractions for 4 hours. Exercises included raised motions of the forehead and scowls – such as knitting the brows – in three sets of 40 repetitions separated by 10 minutes, according to a Northwestern University press release. At 7 months, the women came back for treatment, and switched groups.

Two blinded dermatologists rated photos of forehead and glabella dynamic creases at baseline and on days 1,2,3,4,7, and 14 with the 5-point Carruthers’ Forehead Lines Grading Scale and the 4-point Gladys study group rating scale for glabellar frown lines. The women also assessed their own dynamic creases using a 7-point Subject Self-Evaluation Improvement Scale.

By day 3, ratings by dermatologists and patients of glabellar and forehead wrinkles were statistically significantly better for patients who had performed the exercises after the injections. When facial exercises followed the injections, women said they saw noticeable glabellar improvement by day 2 or 3, compared with day 3 or 4 among those who did not do facial exercises after the injections (P = .02).

“A significant advantage in the exercise group was detectable as early as day 3, at which point patients’ self-evaluation wrinkle scores increased by approximately twice as much in exercisers compared to non-exercisers,” the study authors noted.

But by 2 weeks, the effects of treatment were similar in both groups, and the effects of treatment lasted for a similar period of time with or without exercises.

“Expediting the time to noticeable benefit, even by one day, may be clinically significant for some patients,” the authors wrote. Exercises could be recommended only to those patients who need faster results “to avoid needless inconvenience,” they added.

The study was supported by research funds from the department of dermatology at Northwestern University. The authors had no relevant disclosures.

SOURCE: Alam M et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.10.013.

Performing facial muscle exercises after botulinum toxin injections to the forehead speeds up the clinical effects of the injections by 1 day, a small, randomized study has shown.

The study addressed the lack of data regarding whether exercising treated muscles for several hours after injections helped “to enhance uptake” of botulinum toxin, said Murad Alam, MD, chief of cutaneous and aesthetic surgery and a professor of dermatology at Northwestern University, Chicago, and his coauthors.

“The results of this study suggest that a postinjection facial exercise regimen is a safe and effective method for achieving an earlier onset of clinical effect of botulinum toxin injections,” he and his coauthors concluded. The results were reported in the Journal of the American Academy of Dermatology.

The study enrolled 22 women, aged 27-66 years (mean age, 47 years) who received botulinum toxin injections for forehead and glabella dynamic rhytids. Following the injections, half of the women did the exercises for 4 hours and the other half avoided facial contractions for 4 hours. Exercises included raised motions of the forehead and scowls – such as knitting the brows – in three sets of 40 repetitions separated by 10 minutes, according to a Northwestern University press release. At 7 months, the women came back for treatment, and switched groups.

Two blinded dermatologists rated photos of forehead and glabella dynamic creases at baseline and on days 1,2,3,4,7, and 14 with the 5-point Carruthers’ Forehead Lines Grading Scale and the 4-point Gladys study group rating scale for glabellar frown lines. The women also assessed their own dynamic creases using a 7-point Subject Self-Evaluation Improvement Scale.

By day 3, ratings by dermatologists and patients of glabellar and forehead wrinkles were statistically significantly better for patients who had performed the exercises after the injections. When facial exercises followed the injections, women said they saw noticeable glabellar improvement by day 2 or 3, compared with day 3 or 4 among those who did not do facial exercises after the injections (P = .02).

“A significant advantage in the exercise group was detectable as early as day 3, at which point patients’ self-evaluation wrinkle scores increased by approximately twice as much in exercisers compared to non-exercisers,” the study authors noted.

But by 2 weeks, the effects of treatment were similar in both groups, and the effects of treatment lasted for a similar period of time with or without exercises.

“Expediting the time to noticeable benefit, even by one day, may be clinically significant for some patients,” the authors wrote. Exercises could be recommended only to those patients who need faster results “to avoid needless inconvenience,” they added.

The study was supported by research funds from the department of dermatology at Northwestern University. The authors had no relevant disclosures.

SOURCE: Alam M et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.10.013.

Performing facial muscle exercises after botulinum toxin injections to the forehead speeds up the clinical effects of the injections by 1 day, a small, randomized study has shown.

The study addressed the lack of data regarding whether exercising treated muscles for several hours after injections helped “to enhance uptake” of botulinum toxin, said Murad Alam, MD, chief of cutaneous and aesthetic surgery and a professor of dermatology at Northwestern University, Chicago, and his coauthors.

“The results of this study suggest that a postinjection facial exercise regimen is a safe and effective method for achieving an earlier onset of clinical effect of botulinum toxin injections,” he and his coauthors concluded. The results were reported in the Journal of the American Academy of Dermatology.

The study enrolled 22 women, aged 27-66 years (mean age, 47 years) who received botulinum toxin injections for forehead and glabella dynamic rhytids. Following the injections, half of the women did the exercises for 4 hours and the other half avoided facial contractions for 4 hours. Exercises included raised motions of the forehead and scowls – such as knitting the brows – in three sets of 40 repetitions separated by 10 minutes, according to a Northwestern University press release. At 7 months, the women came back for treatment, and switched groups.

Two blinded dermatologists rated photos of forehead and glabella dynamic creases at baseline and on days 1,2,3,4,7, and 14 with the 5-point Carruthers’ Forehead Lines Grading Scale and the 4-point Gladys study group rating scale for glabellar frown lines. The women also assessed their own dynamic creases using a 7-point Subject Self-Evaluation Improvement Scale.

By day 3, ratings by dermatologists and patients of glabellar and forehead wrinkles were statistically significantly better for patients who had performed the exercises after the injections. When facial exercises followed the injections, women said they saw noticeable glabellar improvement by day 2 or 3, compared with day 3 or 4 among those who did not do facial exercises after the injections (P = .02).

“A significant advantage in the exercise group was detectable as early as day 3, at which point patients’ self-evaluation wrinkle scores increased by approximately twice as much in exercisers compared to non-exercisers,” the study authors noted.

But by 2 weeks, the effects of treatment were similar in both groups, and the effects of treatment lasted for a similar period of time with or without exercises.

“Expediting the time to noticeable benefit, even by one day, may be clinically significant for some patients,” the authors wrote. Exercises could be recommended only to those patients who need faster results “to avoid needless inconvenience,” they added.

The study was supported by research funds from the department of dermatology at Northwestern University. The authors had no relevant disclosures.

SOURCE: Alam M et al. J Am Acad Dermatol. 2018. doi: 10.1016/j.jaad.2018.10.013.

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at dermnews@mededge.com.

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at dermnews@mededge.com.

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

Taurine, also known as 2-aminoethanesulfonic acid, is a naturally occurring beta-amino acid (which has a sulphonic acid group instead of carboxylic acid, differentiating it from other amino acids) yielded by methionine and cysteine metabolism in the liver.^1,2 An important free beta-amino acid in mammals, it is often the free amino acid present in the greatest concentrations in several cell types in humans.^1,2 Dietary intake of taurine also plays an important role in maintaining the body’s taurine levels because of mammals’ limited ability to synthesize it.¹

olavs/Thinkstock

Notably in terms of dermatologic treatment options, the combination product taurine bromamine is known to impart antioxidant, anti-inflammatory, and antibacterial activities.³ And taurine itself is associated with antioxidant, anti-inflammatory, antifibrotic, and immunomodulatory characteristics,^1,4 and is noted for conferring antiaging benefits.⁵

Acne and other inflammatory conditions

The use of topical taurine bromamine, the physiological product of hypobromous acid and taurine, is one of the new emerging approaches to treating acne.^6,7

In response to the problem of evolving antibiotic resistance, Marcinkiewicz reported in 2009 on the then-new therapeutic option of topical taurine bromamine for the treatment of inflammatory skin disorders such as acne. The author pointed out that Propionibacterium acnes is particularly sensitive to taurine bromamine, with the substance now known to suppress H₂O₂ production by activated neutrophils, likely contributing to moderating the severity and lowering the number of inflammatory acne lesions. In a 6-week double-blind pilot clinical study, Marcinkiewicz and his team compared the efficacy of 0.5% taurine bromamine cream with 1% clindamycin gel in 40 patients with mild to moderate acne. Treatments, which were randomly assigned, occurred twice daily through the study. Amelioration of acne symptoms was comparable in the two groups, with more than 90% of patients improving clinically and experiencing similar decreases in acne lesions (65% in the taurine bromamine group and 68% in the clindamycin group). Marcinkiewicz concluded that these results indicate the viability of taurine bromamine as an option for inflammatory acne therapy, particularly for patients who have shown antibiotic resistance.³

Wide-ranging protection potential

In 2003, Janeke et al. conducted analyses that showed that taurine accumulation defended cultured human keratinocytes from osmotically- and UV-induced apoptosis, suggesting the importance of taurine as an epidermal osmolyte necessary for maintaining keratinocyte hydration in a dry environment.²

Three years later, Collin et al. demonstrated the dynamic protective effects of taurine on the human hair follicle in an in vitro study in which taurine promoted hair survival and protected against TGF-beta1-induced damage.¹

Taurine has also been found to stabilize and protect the catalytic activity of the hemoprotein cytochrome P450 3A4, which is a key enzyme responsible for metabolizing various endogenous as well as foreign substances, including drugs.⁸
 

Penetration enhancement

In 2016, Mueller et al. studied the effects of urea and taurine as hydrophilic penetration enhancers on stratum corneum lipid models as both substances are known to exert such effects. With inconclusive results as to the roots of such activity, they speculated that both entities enhance penetration through the introduction of copious water into the corneocytes, resulting from the robust water-binding capacity of urea and the consequent osmotic pressure related to taurine.⁹

Possible skin whitening and anti-aging roles and other promising lab results

Based on their previous work demonstrating that azelaic acid, a saturated dicarboxylic acid found naturally in wheat, rye, and barley, suppressed melanogenesis, Yu and Kim investigated the antimelanogenic activity of azelaic acid and taurine in B16F10 mouse melanoma cells in 2010. They found that the combination of the two substances exhibited a greater inhibitory effect in melanocytes than azelaic acid alone, with melanin production and tyrosinase activity suppressed without inducing cytotoxicity. The investigators concluded the combination of azelaic acid and taurine may be an effective approach for treating hyperpigmentation.¹⁰

In 2015, Ito et al. investigated the possible anti-aging role of taurine using a taurine transporter knockout mouse model. They noted that aging-related disorders affecting the skin, heart, skeletal muscle, and liver and resulting in a shorter lifespan have been correlated with tissue taurine depletion. The researchers proposed that proper protein folding allows endogenous taurine to perform as an antiaging molecule.⁵

Also in 2015, Kim et al. investigated potential mechanisms of the antiproliferative activity of taurine on murine B16F10 melanoma cells via the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) and neutral red assays and microscopic analysis. They found that taurine prevented cell proliferation and engendered apoptosis in B16F10 cells, concluding that taurine may have a role to play as a chemotherapeutic agent for skin cancer.¹¹

In 2014, Ashkani-Esfahani et al. studied the impact of taurine on cutaneous leishmaniasis wounds in a mouse model. Investigators induced 18 mice with wounds using L. major promastigotes, and divided them into a taurine injection group, taurine gel group, and no treatment group, performing treatments every 24 hours over 21 days. The taurine treatment groups exhibited significantly greater numerical fibroblast density, collagen bundle volume density, and vessel length densities compared with the nontreatment group. The taurine injection group displayed higher fibroblast numerical density than did the taurine gel group. The researchers concluded that taurine has the capacity to enhance wound healing and tissue regeneration but showed no direct anti-leishmaniasis effect.⁴

Conclusion

Taurine has been found over the last few decades to impart salutary effects for human health. This beta-amino acid that occurs naturally in humans and other mammals also appears to hold promising potential in the dermatologic realm, particularly for its anti-inflammatory and antioxidant effects. More research is needed to ascertain just how pivotal this compound can be for skin health.

Dr. Baumann is a private practice dermatologist, researcher, author and entrepreneur who practices in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote two textbooks: “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and “Cosmeceuticals and Cosmetic Ingredients,” (New York: McGraw-Hill, 2014), and a New York Times Best Sellers book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). Dr. Baumann has received funding for advisory boards and/or clinical research trials from Allergan, Evolus, Galderma, and Revance. She is the founder and CEO of Skin Type Solutions Franchise Systems LLC. Write to her at dermnews@mededge.com.

References

1. Int J Cosmet Sci. 2006 Aug;28(4):289-98.

2. J Invest Dermatol. 2003 Aug;121(2):354-61.

3. Pol Arch Med Wewn. 2009 Oct;119(10):673-6.

4. Adv Biomed Res. 2014 Oct 7;3:204.

5. Adv Exp Med Biol. 2015;803:481-7.

6. Am J Clin Dermatol. 2012 Dec 1;13(6):357-64.

7. Eur J Dermatol. 2008 Jul-Aug;18(4):433-9.

8. Biochemistry (Mosc). 2015 Mar;80(3):366-73.

9. Biochim Biophys Acta. 2016 Sep;1858(9):2006-18.

10. J Biomed Sci. 2010 Aug 24;17 Suppl 1:S45.

11. Adv Exp Med Biol. 2015;803:167-77.

Autologous treatment with injected platelet-rich plasma (PRP) yielded substantial improvement in hair count and shaft thickness in patients with androgenetic alopecia (AGA) after three monthly treatments, in a study that compared two treatment regimens.

PRP is gaining popularity because of its efficacy in stimulating fibroblast proliferation, triggering the production of collagen and elastin, and boosting the quantity and quality of the extracellular matrix, noted the investigators, Amelia K. Hausauer, MD, in private practice in Campbell, Calif., and Derek H. Jones, MD, in private practice in Los Angeles. Both are also with the department of dermatology at the University of California, Los Angeles.

They undertook this study to determine the optimal number and timing of treatments in patients with AGA, comparing two different injection protocols over a 6-month period. The study evaluated 40 healthy men (30) and women (10), whose mean age was 44 years, with AGA stages Norwood-Hamilton II-V (in men) and Ludwig I2-II1 (in women), recruited from a private practice in Los Angeles between November 2016 and January 2017. They were randomly assigned to one of two treatment groups: three monthly sessions followed by a fourth injection 3 months later (group 1), or two treatments, one at baseline and the second 3 months later (group 2). One of the men dropped out for reasons unrelated to the treatment.

Those with clinically stable effects of Food and Drug Administration–approved AGA treatments for 12 months were permitted to participate while continuing those treatments (topical minoxidil and/or oral finasteride), since PRP is often coadministered with other therapies. But additional products, devices, or medications used for hair regrowth were not allowed. The washout period for antiandrogen therapies was 90 days.

At 3 months, the mean increase in hair counts was significant in the first group only, but at 6 months, both groups experienced significant increases in hair count (P less than .001). However, those in the first group had superior results at 6 months, with a mean 30% increase in hair counts from baseline, compared with a 7% increase in the second group (P less than .001).

Both groups had significant increases in the mean hair shaft caliber at 3 and 6 months.

Overall, 82% of participants who completed treatment reported being satisfied or highly satisfied, and 72% expressed interest in continuing treatment after the study period; almost two-thirds considered the procedure “tolerable.”

While the authors stipulated that they did not undertake the study primarily to predict treatment response to PRP, they uncovered some significant trends that they said warranted further evaluation, including the finding that those who had experienced hair loss for less than 5-6 years were more likely to have rapid and pronounced treatment response.

Their overall findings correlated with those of previous studies supporting the increase in density of hair or hair numbers, but the existing literature draws from studies that have been open label or unblinded, which makes it difficult to evaluate them head to head. The novel, subdermal injection technique used in the study “allows for fewer, more widely spaced injection points than the traditional nappage procedure ... because PRP can diffuse further once in the deeper, subgaleal space,” they wrote. The investigators noted similar response between men and women, which is important given sparse data on the efficacy of PRP in women.

Weaknesses of the study included its small sample size and short follow-up period, the authors noted. Longer-duration studies have reported relapse between 3 and 12 months.

This study is the first of its kind to directly compare efficacy rates of two injection protocols, the authors wrote, cautioning that future studies are necessary to “fine-tune preparation methods, determine optimal maintenance schedule(s), and parse out clinical predictors of efficacy.”

Eclipse Aesthetics (the manufacturer of the PRP preparation kits) provided funding for this study, but the authors acknowledged no significant interest with commercial supporters.

SOURCE: Hausauer A et al. Dermatol Surg. 2018 Sep;44(9):1191-200.

Autologous treatment with injected platelet-rich plasma (PRP) yielded substantial improvement in hair count and shaft thickness in patients with androgenetic alopecia (AGA) after three monthly treatments, in a study that compared two treatment regimens.

PRP is gaining popularity because of its efficacy in stimulating fibroblast proliferation, triggering the production of collagen and elastin, and boosting the quantity and quality of the extracellular matrix, noted the investigators, Amelia K. Hausauer, MD, in private practice in Campbell, Calif., and Derek H. Jones, MD, in private practice in Los Angeles. Both are also with the department of dermatology at the University of California, Los Angeles.

They undertook this study to determine the optimal number and timing of treatments in patients with AGA, comparing two different injection protocols over a 6-month period. The study evaluated 40 healthy men (30) and women (10), whose mean age was 44 years, with AGA stages Norwood-Hamilton II-V (in men) and Ludwig I2-II1 (in women), recruited from a private practice in Los Angeles between November 2016 and January 2017. They were randomly assigned to one of two treatment groups: three monthly sessions followed by a fourth injection 3 months later (group 1), or two treatments, one at baseline and the second 3 months later (group 2). One of the men dropped out for reasons unrelated to the treatment.

Those with clinically stable effects of Food and Drug Administration–approved AGA treatments for 12 months were permitted to participate while continuing those treatments (topical minoxidil and/or oral finasteride), since PRP is often coadministered with other therapies. But additional products, devices, or medications used for hair regrowth were not allowed. The washout period for antiandrogen therapies was 90 days.

At 3 months, the mean increase in hair counts was significant in the first group only, but at 6 months, both groups experienced significant increases in hair count (P less than .001). However, those in the first group had superior results at 6 months, with a mean 30% increase in hair counts from baseline, compared with a 7% increase in the second group (P less than .001).

Both groups had significant increases in the mean hair shaft caliber at 3 and 6 months.

Overall, 82% of participants who completed treatment reported being satisfied or highly satisfied, and 72% expressed interest in continuing treatment after the study period; almost two-thirds considered the procedure “tolerable.”

While the authors stipulated that they did not undertake the study primarily to predict treatment response to PRP, they uncovered some significant trends that they said warranted further evaluation, including the finding that those who had experienced hair loss for less than 5-6 years were more likely to have rapid and pronounced treatment response.

Their overall findings correlated with those of previous studies supporting the increase in density of hair or hair numbers, but the existing literature draws from studies that have been open label or unblinded, which makes it difficult to evaluate them head to head. The novel, subdermal injection technique used in the study “allows for fewer, more widely spaced injection points than the traditional nappage procedure ... because PRP can diffuse further once in the deeper, subgaleal space,” they wrote. The investigators noted similar response between men and women, which is important given sparse data on the efficacy of PRP in women.

Weaknesses of the study included its small sample size and short follow-up period, the authors noted. Longer-duration studies have reported relapse between 3 and 12 months.

This study is the first of its kind to directly compare efficacy rates of two injection protocols, the authors wrote, cautioning that future studies are necessary to “fine-tune preparation methods, determine optimal maintenance schedule(s), and parse out clinical predictors of efficacy.”

Eclipse Aesthetics (the manufacturer of the PRP preparation kits) provided funding for this study, but the authors acknowledged no significant interest with commercial supporters.

SOURCE: Hausauer A et al. Dermatol Surg. 2018 Sep;44(9):1191-200.

Autologous treatment with injected platelet-rich plasma (PRP) yielded substantial improvement in hair count and shaft thickness in patients with androgenetic alopecia (AGA) after three monthly treatments, in a study that compared two treatment regimens.

PRP is gaining popularity because of its efficacy in stimulating fibroblast proliferation, triggering the production of collagen and elastin, and boosting the quantity and quality of the extracellular matrix, noted the investigators, Amelia K. Hausauer, MD, in private practice in Campbell, Calif., and Derek H. Jones, MD, in private practice in Los Angeles. Both are also with the department of dermatology at the University of California, Los Angeles.

They undertook this study to determine the optimal number and timing of treatments in patients with AGA, comparing two different injection protocols over a 6-month period. The study evaluated 40 healthy men (30) and women (10), whose mean age was 44 years, with AGA stages Norwood-Hamilton II-V (in men) and Ludwig I2-II1 (in women), recruited from a private practice in Los Angeles between November 2016 and January 2017. They were randomly assigned to one of two treatment groups: three monthly sessions followed by a fourth injection 3 months later (group 1), or two treatments, one at baseline and the second 3 months later (group 2). One of the men dropped out for reasons unrelated to the treatment.

Those with clinically stable effects of Food and Drug Administration–approved AGA treatments for 12 months were permitted to participate while continuing those treatments (topical minoxidil and/or oral finasteride), since PRP is often coadministered with other therapies. But additional products, devices, or medications used for hair regrowth were not allowed. The washout period for antiandrogen therapies was 90 days.

At 3 months, the mean increase in hair counts was significant in the first group only, but at 6 months, both groups experienced significant increases in hair count (P less than .001). However, those in the first group had superior results at 6 months, with a mean 30% increase in hair counts from baseline, compared with a 7% increase in the second group (P less than .001).

Both groups had significant increases in the mean hair shaft caliber at 3 and 6 months.

Overall, 82% of participants who completed treatment reported being satisfied or highly satisfied, and 72% expressed interest in continuing treatment after the study period; almost two-thirds considered the procedure “tolerable.”

While the authors stipulated that they did not undertake the study primarily to predict treatment response to PRP, they uncovered some significant trends that they said warranted further evaluation, including the finding that those who had experienced hair loss for less than 5-6 years were more likely to have rapid and pronounced treatment response.

Their overall findings correlated with those of previous studies supporting the increase in density of hair or hair numbers, but the existing literature draws from studies that have been open label or unblinded, which makes it difficult to evaluate them head to head. The novel, subdermal injection technique used in the study “allows for fewer, more widely spaced injection points than the traditional nappage procedure ... because PRP can diffuse further once in the deeper, subgaleal space,” they wrote. The investigators noted similar response between men and women, which is important given sparse data on the efficacy of PRP in women.

Weaknesses of the study included its small sample size and short follow-up period, the authors noted. Longer-duration studies have reported relapse between 3 and 12 months.

This study is the first of its kind to directly compare efficacy rates of two injection protocols, the authors wrote, cautioning that future studies are necessary to “fine-tune preparation methods, determine optimal maintenance schedule(s), and parse out clinical predictors of efficacy.”

Eclipse Aesthetics (the manufacturer of the PRP preparation kits) provided funding for this study, but the authors acknowledged no significant interest with commercial supporters.

SOURCE: Hausauer A et al. Dermatol Surg. 2018 Sep;44(9):1191-200.

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com



 

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com



 

SAN DIEGO – Hair removal has been ranked as the most commonly litigated procedure in laser surgery, although fewer procedures for hair removal are performed annually than for other applications, Kristen M. Kelly, MD, said at the annual Masters of Aesthetics Symposium.

Clinicians perform an estimated 445,000 laser hair removal procedures each year, trailing those performed for wrinkles (561,000), facial redness (598,000), and sun damage (610,000), according to the 2017 American Society for Dermatologic Surgery Procedures Survey. However, hair removal has been found to be the most common procedure resulting in litigation (JAMA Dermatol. 2013;149[2]:188-93), “which is what we want to avoid,” Dr. Kelly said. “We want to learn how to do it in the best way possible.”

Dr. Kelly, professor of dermatology and surgery at the University of California, Irvine, pointed out that clinicians are targeting melanin during laser hair removal. “This is important because it means that gray, white, blonde, and in some cases, red hair are not going to respond very well. In order to reach stem cells in the hair follicle, you can’t use superficial wavelengths, so we end up using the 755-nm alexandrite laser, 810-nm diode laser, or the 1064-nm long-pulsed Nd:YAG laser for the most part in order to get our result. You can also use intense pulsed light at 590-1200 nm.”

The pulse duration should be on the order of the thermal relaxation time (TRT) of the target. She defined thermal relaxation time as the duration required for the heat generated by absorbed light energy within the chromophore to dissipate to 50% of its value immediately after laser exposure.

“We want that heat to be absorbed by the melanin in the hair,” Dr. Kelly said. “Then we want that heat to radiate out to the hair follicle and the stem cells, which is going to prevent the hair from coming back in the future.” Epidermal cooling via cryogen spray cooling, contact cooling, or air-cooling allows clinicians to use higher fluences, allows for the use of safe treatment of darker skin types, and decreases treatment discomfort.

Prior to performing laser hair removal on the perioral area, Dr. Kelly provides a prophylactic antiviral medication for patients with a history of herpetic infection to suppress recurrence. She also advises patients to remove sunless tanner or other products from the skin surface, and she shaves or clips hair close to the surface gently, avoiding abrasion or surface damage. Most of the time she does not use a topical anesthetic. “You always want to make sure the laser is functioning properly by checking the laser’s cooling components, etc.,” she said. “I always tell patients, ‘8-10 treatments is not uncommon. You’re going to have fewer hairs and thinner hairs, but it doesn’t mean that you’re going to have zero hairs in this area for the rest of your life.’ Set the expectation correctly.”

Patients should wear protective goggles if being treated in areas other than the face. “If being treated on the face, make sure they’re wearing appropriate protective eyewear such as laser safe eye shields. Those performing the treatment should wear surgical masks and use a smoke evacuator, as there are multiple known carcinogens and environmental toxins in the plume generated by laser hair removal,” she said (JAMA Dermatol. 2016;152[12]:1320-6).

Factors to consider in choosing treatment settings include hair color, the patient’s skin color, hair thickness, hair density, and body location. For example, the genital area may be more pigmented in some patients, and also may be more sensitive. “If you have thicker and darker hair it’s going to absorb more energy, so you have to adjust your settings,” Dr. Kelly said. She also avoids treating acutely tanned patients. “What you don’t want is for a tanned patient have a complication. I’d rather have them wait 2 or 3 weeks and come back. Sometimes it frustrates them a little, but it is safer.”

At the start of each procedure, Dr. Kelly delivers a couple of pulses then asks patients how uncomfortable they are on a scale from 1 to 10. “It often will vary,” she said. “Even if I’ve seen a patient for 10 treatments, some days it will hurt a little more than others. If the patient says it hurts a lot more than it normally does, you need to stop and think. That tells you that something is not right. They might be too tanned, or perhaps the [device] settings are wrong or the laser’s not functioning properly. Monitor the skin response. It takes time to see the final skin response, so wait before adjusting the energy. You want to see mild redness or mild follicular response. People report a little bit of a burning sensation.”

Postprocedure, she routinely applies a topical steroid such as betamethasone or clobetasol immediately after treatment. “That calms down the inflammatory response. If I see an area that I think is going to blister, I will apply the steroid multiple times until I see that response go away.” She asks patients about their pain level and typically applies ice to the treated area for 10 minutes before they leave the office, and they head home with after-care instructions, including a phone number where Dr. Kelly can be reached if patients have concerns. “I call my patients in the evening to ask how they’re doing, and if they have any questions.”

Dr. Kelly does not do laser hair removal inside the eye orbit or between the eyebrows, “because even with eye shields, you can have a problem,” she said. A potential outcome to be aware of is paradoxical hypertrichosis, or increased hair growth after laser hair removal estimated to occur in 0.6%-10% of patients. She discusses this with patients when consenting them. “Some people say this occurs in darker skin types, while others say it happens in people with thicker hair or thinner hair. Some of it occurs on the edges of the treatment area.” The treatment for paradoxical hypertrichosis is to continue laser hair removal and “try to push the energy just a little bit, but be cautious. It can be a difficult problem to resolve.”

Dr. Kelly has noticed a recent uptick at her practice in gender transition patients seeking hair removal procedures. “Removing facial and chest hair may be desirable, and may be covered by the patient’s health insurance,” she said. “Multiple treatments are required. A thick beard area needs to be approached cautiously.”

She referred to future advances in laser hair removal that may involve the use of topical agents to improve outcomes. For example, Sienna Biopharmaceuticals has developed Topical Photoparticle Therapy which, according to its website, uses “silver particles to absorb laser light and convert the light energy into heat to facilitate local tissue injury ... in the case of unwanted light or mixed pigment hair, which can’t be removed with lasers alone, [this process] targets the hair follicle.”

Dr. Kelly disclosed that she is an advisory consultant to Syneron Candela and Allergan. In addition, Allergan has provided drug products to Dr. Kelly for research purposes, while Solta Medical and ThermiRF have provided her with donated light sources for research or clinical use. Dr. Kelly has also received funding from the Sturge-Weber Foundation, the American Society for Laser Medicine and Surgery, and the National Institutes of Health.

dbrunk@mdedge.com