Faculty Bibliography

BACKGROUND:Melasma can be associated with immense psychosocial stress, which can impact quality of life. One theory suggests that ultraviolet light can increase plasmin activity in keratinocytes, which has led to the investigation of tranexamic acid for treating melasma, since it possesses anti-plasmin properties. The use of laser-assisted drug delivery can also increase the uptake of topical medications. AIMS/OBJECTIVE:A prospective pilot study was performed to assess the utility of combination treatment with low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid for melasma. PATIENTS/METHODS/METHODS:A total of 10 subjects were enrolled. Each received 5 treatments to the full face with a low-energy, low-density 1927 nm fractional thulium fiber laser. Immediately following treatment, topical tranexamic acid was applied, and subjects were instructed to apply it twice daily for 7 days. Clinical measures, quality of life, and patient satisfaction were assessed. RESULTS:Mean improvements in Melasma Area and Severity Index (MASI) scores were 1.1 (P = .0899), 3.5 (P = .0395), and 2.5 (P = .2429) at 30-, 90-, and 180-day follow-up, respectively. Maximum improvement occurred at 90-day follow-up. The mean improvement of Melasma Quality of Life Scale (MELASQOL) score was 9.6 (P = .0024) at 30-day follow-up. In addition to changes in pigmentation, subjects also believed their skin felt better, looked more radiant, and had improvements in skin texture and tone. CONCLUSION/CONCLUSIONS:Combination of low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid improved clinical outcomes and quality of life associated with melasma. This combination treatment was safe, well-tolerated, and well-liked by subjects.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The objectives of this study were to evaluate the safety, tolerability, and efficacy of oxymetazoline hydrochloride cream, 1% (oxymetazoline) when used as an adjunctive treatment with energy-based therapy for patients with moderate to severe facial erythema associated with rosacea. STUDY DESIGN/MATERIALS AND METHODS/METHODS:In this Phase 4, multicenter, interventional, open-label study, eligible patients received one of four energy-based therapies (potassium titanyl phosphate laser, intense pulsed light therapy, pulsed-dye laser Vbeam Perfecta, or pulsed-dye laser Cynergy) on day 1 and day 29 and once-daily application of oxymetazoline on days 3 through 27 and days 31 through 56. Improvement from baseline in Clinician Erythema Assessment (CEA) score, patient satisfaction measures, incidence of treatment-emergent adverse events (TEAEs), and worsening from baseline on dermal tolerability assessments and the Clinician Telangiectasia Assessment (CTA) were assessed. Data were summarized using descriptive statistics. RESULTS:A total of 46 patients (mean age, 51.1 years; 78.3% female) enrolled in this study. Similar numbers of patients received each of the energy-based therapies in addition to oxymetazoline. All patients demonstrated an improvement from baseline in CEA during the study with 39 of 43 evaluable patients (90.7%) demonstrating an improvement 6 hours posttreatment on day 56. Most patients were satisfied or very satisfied with treatment at the end of the study. All TEAEs were mild or moderate in severity. Some patients experienced worsening in dermal tolerability assessment symptoms (range: 4-21 patients; 8.7-45.7%). Worsening in CEA and CTA were each reported by three patients (6.5%) at any time during the study. CONCLUSIONS:Treatment with oxymetazoline as adjunctive therapy with energy-based therapy was safe, well tolerated, and reduced facial erythema in patients with moderate to severe persistent facial erythema associated with rosacea. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

BACKGROUND AND OBJECTIVES/OBJECTIVE:) laser has well-demonstrated safety and efficacy in resurfacing treatment of scars in the adult population and in the treatment of pediatric burn scars. However, there is a paucity of literature regarding laser resurfacing of traumatic and surgical scars for cosmetic benefit in the pediatric population, and in majority of cases previously reported, this was done under general anesthesia. STUDY DESIGN/MATERIALS AND METHODS/METHODS:laser resurfacing (FALR) of traumatic or surgical scars at a single center between 2018 and 2019, inclusive. Primary endpoints included safety and tolerance. RESULTS:A total of 31 FALR treatments were performed in 10 patients with traumatic and surgical scars located on the face (age 4-14 years, Fitzpatrick skin type [FST] I-IV, 60% female). Settings ranged from total energy per session 0.02-0.33 kJ, with a 7-mm tip and 30-50% coverage. Nine patients had two or more treatments (average 3, maximum 8) spaced at least 4 weeks apart. All resurfacing treatments were well-tolerated with local infiltration of 1% lidocaine with epinephrine (1:100,000). Six (67%) patients were treated with additional measures including pulsed dye laser, 1927-nm fractional non-ablative low-energy, low-density laser, or intralesional agents (5-fluorouracil, triamcinolone, botulinum toxin). At follow-up (of varied intervals), short-term erythema, as expected, was seen in six patients, and hyperpigmentation in one case (FST IV), both treated with aforementioned alternate devices. Although gradual, improvement in scar appearance and texture was seen with FALR treatments. No additional scarring, infection, or hypopigmentation was seen. CONCLUSIONS:Treatment with fractional ablative laser resurfacing is safe and well-tolerated in the pediatric population in an outpatient setting with local anesthesia. Traumatic scars may cause significant distress to children and parents alike. Multimodal therapy may lead to optimal cosmesis. Given the excellent tolerability, the authors recommend consideration of laser resurfacing in pediatric patients with traumatic or surgical scars when bothersome, either cosmetically or psychologically. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Minimally and non-invasive cosmetic procedures are on the rise. With the advent of social media, improvements in technology, and the increased visibility of cosmetic dermatologists and plastic surgeons, consumers now have greater access to information about aesthetic procedures.

BACKGROUND:Topical adjuncts have been investigated to improve clinical outcomes associated with laser resurfacing for photodamage and cutaneous aging. One such product is a tripeptide/hexapeptide serum, which has been shown to increase dermal collagen and elastin as well as improve post-procedural recovery following treatments. OBJECTIVE:A randomized, blinded, split-face, comparative trial was performed to assess the utility of a tripeptide/hexapeptide serum as a peri-procedural adjunct to non-ablative fractional laser resurfacing. MATERIALS AND METHODS/METHODS:A total of 20 subjects were enrolled. Each hemiface was randomized to either tripeptide/hexapeptide serum or bland moisturizer for twice daily application starting 14 days prior to first laser treatment and continuing until 60 days after. All subjects received 2 treatments to entire face approximately 1 month apart with 1927nm thulium non-ablative fractional laser. Clinical measures and immediate post-procedural recovery were assessed. RESULTS:For each hemiface, scores improved for all measures, including global photodamage, lentigines, pores, radiance, texture, and tone at 30 and 60 days. The tripeptide/hexapeptide serum had greater improvements for all measures at both time points, except for radiance at 60 days, which was equal. In cases where clinical ratings differed between sides, tripeptide/hexapeptide serum more frequently had the superior outcome. Overall, subjects were satisfied with tripeptide/hexapeptide serum. No significant adverse events were observed. CONCLUSION/CONCLUSIONS:Addition of tripeptide/hexapeptide serum as a peri-procedural adjunct to non-ablative fractional laser resurfacing improved various clinical measures of photodamage and cutaneous aging and the immediate post-procedural recovery. The tripeptide/hexapeptide serum was demonstrated to be safe, well-tolerated, and well-liked by subjects.

Recent demand for minimally and non-invasive cosmetic procedures has been rising. According to the American Society for Dermatologic Surgery (ASDS), the numbers of injectable neuromodulator and soft-tissue filler procedures have increased by 42% and 78%, respectively, since 2012.¹ Similarly, laser, light, and energy-based treatments have increased by 74%. Although it has been anecdotally reported that the popularity of dermatologic procedures may peak during specific times of the year, available data on consumer behavior is limited.^2,3 Understanding seasonal trends can offer insights to better forecast patient demand and optimize practice management. In order to fill this gap in the literature, we performed a temporal analysis of various procedures in a busy dermatology clinic.

This commentary examines the recent general movement in the field of cosmetic dermatology toward imitation and reproduction. The issues of medical spas, nonphysician operators, and counterfeit products have recently garnered interest in aesthetic dermatology. As physicians, it is our professional and bioethical responsibility to ensure that our patients are educated on the presence of medical spas, nonphysician operators, and counterfeit products in our field, especially given the discrepancies in patient safety and outcomes. There are also actions that dermatologists can take in order to help differentiate themselves in this current market. This will not only protect our field, but also our patients, who we are obligated to provide high-quality care for as physicians.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Q-switched (QS) and picosecond lasers can effectively and safely remove unwanted tattoo pigments. Cosmetic mucosal tattoos are rare and there are only a handful of cases of successful laser tattoo removal, all with QS 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. STUDY DESIGN/MATERIALS AND METHODS/METHODS:A 19-year-old Fitzpatrick skin-type II female presented for treatment of a 6-month-old, black tattoo on the mucosal surface of her lower lip. She underwent six treatment sessions with a QS 694-nm ruby laser on months 0, 1, 3, 5, 7, and 12. A 30-year-old Fitzpatrick skin-type IV male presented for treatment of a 10-year-old black tattoo on his left buccal mucosa. He underwent one treatment with 755-nm alexandrite picosecond lasers. RESULTS:One month after last treatment, both patients demonstrated marked improvement to the treatment area without scarring or dyspigmentation. CONCLUSIONS:Given the excellent results seen in the patients presented here, the authors recommend that lasers should be the first-line treatment for the removal of unwanted cosmetic mucosal tattoos, which are typically easier to remove than cutaneous tattoos and can be accomplished with various wavelengths in the picosecond and nanosecond domains. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The clinical phenomenon of a cosmetic procedure use disorder has not been formally introduced into the medical lexicon. However, anecdotal clinical experience from physicians and the popular media indicates that there may be a subset of patients who demonstrate addictive-like behaviours [Landsverk G. The 'human Ken doll' has spent more than $750,000 on 72 cosmetic surgeries, and doctors warn that his addiction has gotten dangerous. Available at: https://urldefense.com/v3/__https://www.insider.com/hu__;!!MXfaZl3l!PwVrW7_JP2tY0xvqxwLQjbKx-1gEoGBvlIefnofQPZZtBvMl4YTGebXm0UP5qVRx$ man-ken-doll-plastic-surgery-addiction-2019-10 (last accessed 14 April 2020]. To date, the only other investigation establishing a role of addiction psychiatry in aesthetic treatmentseeking behaviour is with ultraviolet light tanning (Warthan MM, Uchida T, Wagner Jr RF. UV light tanning as a type of substance-related disorder. JAMA Dermatol 2005; 141: 963-6). We aimed to investigate the possibility of a novel diagnosis of substance-related use disorder involving cosmetic procedures. We hypothesize that individuals with abuse or dependence on cosmetic procedures exist and can be captured through the administration of modified questionnaires designed to detect alcohol use disorder (AUD). We implemented a cross-sectional survey study of self-identified behaviour with cosmetic procedures. Two validated instruments, the CAGE (Cut down, Annoyed, Guilty, Eye-opener) questionnaire and Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for AUD, were modified to evaluate patients for abuse or dependence on cosmetic procedures. Adults (> 18 years) were surveyed in a waiting room of a laser and skin surgery private practice in New York. Respondents were included if they indicated having received at least one cosmetic procedure in the past 12 months. A positive response on the modified CAGE questionnaire was a score of 2 or more out of four questions, which is similar to the cutoff for AUD screening. Positive findings on the modified DSM-5 questionnaire was defined as two or more out of 11 questions, which is similar to the cutoff for a diagnosis of AUD. Statistical association of the two diagnostic instruments was performed using the Pearson c2-test. Of the 55 participants, six (11%) met the modified CAGE criteria and 13 (24%) met modified DSM-5 criteria, indicating that a subset of individuals may qualify for abuse or dependence on cosmetic procedures. The results from both instruments were significantly associated (P = 0.0019). A novel type of substance-related disorder involving cosmetic procedures may exist. Further investigations with larger and varied study populations may validate these findings and ascertain the nature of the dependence and its relation to increased utilization. Validated screening tools may help physicians recognize these patients, guide informed consent, and provide risk-benefit counselling prior to the initiation of cosmetic procedures