Integrative skincare trial of intense pulsed light followed by the phyto-corrective mask, phyto-corrective gel, and resveratrol BE for decreasing post-procedure downtime and improving procedure outcomes in patients with rosacea

BACKGROUND

Rosacea is a chronic inflammatory skin condition of varying severity that can significantly impact patient quality of life. Intense pulsed light (IPL) is an established treatment for rosacea-associated telangiectasia, inflammation, and erythema. This study assessed whether application of a phyto-corrective mask, gel, and resveratrol antioxidant serum after IPL treatment can improve outcomes and reduce procedure-related adverse effects.

METHODS

In a prospective, open-label, split-face, 3-month study, 10 subjects with moderate-to-severe facial rosacea underwent IPL treatment on both sides of the face. The following were applied to the right side of the face only: phyto-corrective mask once weekly starting immediately after IPL; phyto-corrective gel twice daily; and resveratrol antioxidant treatment at night. Both sides of the face were treated with sunscreen. Subjects were assessed on Day 1, 1 and 3 months after IPL by three, independent evaluators using the 5-point Global Aesthetic Improvement Scale (GAIS). All subjects rated skin redness, hydration, and overall improvement on Day 1 and completed a patient satisfaction questionnaire at the 1- and 3-month visits.

RESULTS

Ten women were enrolled, aged 44-72 years old, with moderate (n = 6) to severe (n = 4) rosacea. IPL was effective at reducing symptoms with rosacea classified as absent in five women and mild in five at the final 3-month visit. GAIS scores also revealed improvements on both sides of the face, but the skincare treated side showed continuous improvement over 3 months with all patients remaining at least "Improved", whereas there appeared to be a waning effect after 1 month with IPL alone. On Day 1 after IPL, all women reported less redness, improved hydration, and improved skin appearance on the right side of the face. Patient satisfaction was consistently rated higher on the right side of the face.

CONCLUSION

Application of a phyto-corrective mask, gel, and resveratrol antioxidant serum may complement IPL treatment for rosacea by enhancing treatment outcomes and reducing procedure-related symptoms.

Nonmelanoma Skin Cancer in Patients Older Than Age 85 Years Presenting for Mohs Surgery: A Prospective, Multicenter Cohort Study

Importance

It has been suggested that Mohs surgery for skin cancer among individuals with limited life expectancy may be associated with needless risk and discomfort, along with increased health care costs.

Objective

To investigate patient- and tumor-specific indications considered by clinicians for treatment of nonmelanoma skin cancer in older individuals.

Design, Setting, and Participants

This multicenter, prospective cohort study was conducted using data from US private practice and academic centers. Included patients were those older than age 85 years presenting for skin cancer surgery and referred for Mohs surgery, with reference groups of those younger than age 85 years receiving Mohs surgery and those older than age 85 years not receiving Mohs surgery. Data were analyzed from November 2018 through January 2019.

Exposures

Mohs surgery for nonmelanoma skin cancer.

Main Outcomes and Measures

Reason for treatment selection.

Results

Among 1181 patients older than age 85 years referred for Mohs surgery (724 [61.9%] men among 1169 patients with sex data; 681 individuals aged >85 to 88 years [57.9%] among 1176 patients with age data) treated at 22 sites, 1078 patients (91.3%) were treated by Mohs surgery, and 103 patients (8.7%) received alternate treatment. Patients receiving Mohs surgery were more likely to have tumors on the face (738 patients [68.5%] vs 26 patients [25.2%]; P < .001) and nearly 4-fold more likely to have high functional status (614 patients [57.0%] vs 16 patients [15.5%]; P < .001). Of 15 distinct reasons provided by surgeons for opting to proceed with Mohs surgery, the most common were patient desire for treatment with a high cure rate (712 patients [66.0%]), good or excellent patient functional status for age (614 patients [57.0%]), and high risk associated with the tumor based on histology (433 patients [40.2%]).

Conclusions and Relevance

This study found that older patients who received Mohs surgery often had high functional status, high-risk tumors, and tumors located on the face. These findings suggest that timely surgical treatment may be appropriate in older patients given that their tumors may be aggressive, painful, disfiguring, and anxiety provoking.

Postmarket Safety Surveillance of Delayed Complications for Recent FDA-Approved Hyaluronic Acid Dermal Fillers

OBJECTIVE

To review postmarketing data for delayed (≥14 days post-treatment) adverse events (AEs) of interest (inflammatory and noninflammatory nodules, hypersensitivity, granulomas) for newer hyaluronic acid (HA) fillers FDA-approved within the last 5 years (2016-2020).

METHODS

Reports from the Manufacturer and User Facility Device Experience (MAUDE) database were extracted for HAREF, HADEF, HAKYS, HAVER, HAVLR, HAVOB, HARH2, HARH3, and HARH4 from January 2016 to January 2021. Keywords from event narratives were used to identify and categorize AEs and then verified through inclusion/exclusion criteria. Percentages are based on the total combined events of interest to provide an overall perspective of the events reported during the search period.

RESULTS

Of 585 MAUDE reports, there were 195 (33.3%) delayed AEs of interest. Of those, 71.8% were nodules (42.1% inflammatory and 29.7% noninflammatory), 21.5% hypersensitivity, and 6.7% granulomas. The combined total events of interest, ordered by frequency reported, were HAVLR (74.4%), HAVOB (12.3%), HADEF (5.1%), HARH4 (3.6%), HAREF (2.6%), and HARH2 (2.1%), with no reports for HARH3, HAVER, and HAKYS.

CONCLUSION

Although delayed nodules and inflammatory events are rare, reports for these events were extracted from the MAUDE database from 2016 to 2020 for HAVLR, HAVOB, HADEF, HARH4, HAREF, and HARH2 (most to least frequent).

Risk factors and prevention strategies for cutaneous squamous cell carcinoma in transplant recipients

It has been well established that organ transplant recipients (OTRs) are at an increased risk of skin cancer. Studies vary on the exact degree of this risk, but it is likely somewhere between 60 and 100 times more likely that an OTR patient will develop skin cancer. The management of skin cancer burden in OTRs requires a multidisciplinary approach with the transplant team, dermatologists, and oncology. In many major hospital systems, there are dedicated transplant dermatology clinics that allow for specialized and more frequent screenings of this high-risk population. Here we discuss the pathogenesis, presentation, and treatment options used by dermatologists to prevent and treat commonly found skin cancers in this vulnerable population.

Multimodal Facial Aesthetic Treatment on the Appearance of Aging, Social Confidence, and Psychological Well-being: HARMONY Study

Background

A global approach to facial rejuvenation involves multiple treatment modalities.

Objectives

The aim of this study was to evaluate the impact of multimodal facial aesthetic treatment on self-reported psychological and social outcomes.

Methods

HARMONY, a prospective, multicenter, 4-month study, enrolled patients aged 35 to 65 years to receive on-label treatment with a combination of hyaluronic fillers (VYC-20L, HYC-24L, and/or HYC-24L+), onabotulinumtoxinA, and bimatoprost. Fillers were injected on Day 1, with touch-ups performed on Day 14. OnabotulinumtoxinA was injected at Month 3 into glabellar lines and/or crow’s feet lines. Patients applied bimatoprost to eyelashes once daily for 17 weeks. Mean change from baseline on FACE-Q Psychological Well-being and Social Confidence Scales, FACE-Q Aging Appearance Appraisal Scale, and FACE-Q Age Appraisal Visual Analog Scale were assessed.

Results

Of 100 patients treated, 93 were evaluated at 4 months posttreatment. Significant improvement vs baseline was observed on the FACE-Q Scales for Psychological Well-being (mean change, −19.9; P < 0.00001), Social Confidence (mean change, −18.2; P < 0.00001), and Aging Appearance (mean change, −28.5; P < 0.0001). On average, patients’ self-assessed age was 0.1 years older than actual age at baseline and 4.5 years younger at Month 4 (P < 0.001 vs baseline). Forty-two patients experienced adverse events, all mild to moderate.

Conclusions

Multimodal, full facial aesthetic treatment improves patients’ self-reported psychological well-being, social confidence, aging appearance, and perceptions of chronologic age.

Level of Evidence: 4

The Second of Two One-Year, Multicenter, Open-Label, Repeat-Dose, Phase II Safety Studies of PrabotulinumtoxinA for the Treatment of Moderate to Severe Glabellar Lines in Adult Patients

BACKGROUND

PrabotulinumtoxinA is a 900-kDa botulinum toxin type A produced by Clostridium botulinum.

OBJECTIVES

The authors sought to investigate the safety of prabotulinumtoxinA for treatment of glabellar lines.

METHODS

This was a multicenter, open-label, repeat-dose, 1-year phase II safety study. Adults with moderate to severe glabellar lines at maximum frown, as independently assessed by both investigator and patient on the validated 4-point photonumeric Glabellar Line Scale (0 = no lines, 1 = mild, 2 = moderate, 3 = severe), were enrolled. On day 0, patients received an initial treatment (IT) of 20 U prabotulinumtoxinA (4 U/0.1 mL final vacuum-dried formulation injected into 5 glabellar sites). On and after day 90, patients received a repeat treatment (RT) if their Glabellar Line Scale score was ≥2 at maximum frown by investigator assessment. Safety outcomes were evaluated throughout the study.

RESULTS

The 570 study patients received a median total dose of 60 U, that is, 3 treatments. Sixty-one patients (10.7%) experienced adverse events (AEs) assessed as possibly study drug related; 6.5% experienced study drug-related AEs after the IT. With each RT, progressively lower percentages of patients experienced study drug-related AEs. Eight patients (1.4%) experienced study drug-related AEs of special interest: 5 experienced eyelid ptosis (0.9%), 3 eyebrow ptosis (0.5%), 1 blepharospasm (0.2%), and 1 blurred vision (0.2%). Seven patients (1.2%) experienced serious AEs, but none were study drug related. A total of 4060 serum samples were tested for antibotulinum toxin antibodies; no seroconversion was observed.

CONCLUSIONS

The safety of RTs of 20 U of prabotulinumtoxinA for moderate to severe glabellar lines was confirmed in this second phase II study based on a broad range of outcomes.

LEVEL OF EVIDENCE: 2

Improvements in Submental Contour up to 3 Years After ATX-101: Efficacy and Safety Follow-Up of the Phase 3 REFINE Trials

BACKGROUND

ATX-101 (deoxycholic acid) significantly reduced submental fat (SMF) severity in two 24-week Phase 3 studies (REFINE-1 and REFINE-2).

OBJECTIVES

The aim of this study was to evaluate the durability of effect and long-term safety of ATX-101.

METHODS

REFINE study patients who maintained ≥1-grade improvement on the Clinician-Reported SMF Rating Scale (CR-1 responders) 12 weeks after their last REFINE treatment were eligible for enrollment in this multicenter, double-blind, nontreatment, long-term, follow-up study (NCT02163902). The primary endpoint was CR-1 response at Years 1, 2, and 3. Patient-reported satisfaction, psychological impact, and adverse events were monitored.

RESULTS

In total, 224 patients (ATX-101, n = 113; placebo, n = 111) were enrolled. Maintenance of CR-1 response was significantly better in the ATX-101 group than in the placebo group at Year 1 (86.4% vs 56.8%; P < 0.001), Year 2 (90.6% vs 73.8%; P = 0.014), and Year 3 (82.4% vs 65.0%; P = 0.03). Most (74%) ATX-101‒treated patients satisfied at 12 weeks remained satisfied at Year 3. Significant reductions from baseline in psychological impact scores were sustained through Year 3 (P < 0.001). No new treatment-related adverse events were reported.

CONCLUSIONS

Improvements in submental contour achieved with ATX-101 are maintained for 3 years in most patients. No new safety signals emerged.

LEVEL OF EVIDENCE: 2

Photodynamic Therapy with 5-aminolevulinic Acid 10% Gel and Red Light for the Treatment of Actinic Keratosis, Nonmelanoma Skin Cancers, and Acne: Current Evidence and Best Practices

Photodynamic therapy (PDT) can be an effective treatment for actinic keratosis (AK) as well as selected non-melanoma skin cancers (NMSCs), such as Bowen's disease and superficial basal cell carcinoma. PDT has also demonstrated effectiveness in the management of acne vulgaris. Results from controlled clinical trials have shown the safety and efficacy of PDT for these conditions with the use of different photosensitizers and a wide range of light sources. PDT has been employed effectively as monotherapy and in combination with other topicals and alternate light or laser energy therapies. This article provides expert practical guidance for the use of the newest 5-aminolevulinic acid (ALA) product (ALA 10% gel) plus red light as monotherapy for AKs, NMSC, and acne. Here, information from clinical guidelines and a summary of supporting evidence is provided for each cutaneous condition. The authors also provide detailed guidance for employing ALA 10% gel, a photosensitizer precursor, for each of these applications.

Skin Preparation for Photodynamic Therapy, Chemexfoliation, and Ablative Laser Resurfacing: a Systematic Literature Review

BACKGROUND

Photodynamic therapy, chemexfoliation, and ablative laser resurfacing are common practices for dermatologists, yet no formal protocols exist regarding preprocedural skin preparation.

OBJECTIVE

To review and summarize the skin preparation protocols for photodynamic therapy, chemexfoliation, and ablative laser resurfacing available in the literature.

METHODS

Data Sources A systematic review of English and non-English articles using the PubMed database was performed. A manual search of bibliographies from relevant articles was also performed to collect additional studies. Study Selection Only articles in the English language with full texts available that pertained to skin preparation for photodynamic therapy, chemexfoliation, and ablative laser resurfacing were included. Data Extraction Article selection was performed by one author, and relevant sources were verified by other authors using predefined inclusion and exclusion criteria.

RESULTS

There is a paucity of scientific research regarding efficacy and safety of dermatologic preprocedural skin preparation agents. Only 2 studies have compared various cleansing agents for these measures. Yet, strong statements regarding the importance of degreasing are published without supportive data.

CONCLUSION

Consensus guidelines for preprocedural protocols are lacking for photodynamic therapy, chemexfoliation, and ablative laser resurfacing. Further studies are warranted to explore the efficacy and safety of various preprocedural cleansing agents.

Reconstruction of Cutaneous Defects of the Ear Using the Post-Auricular Reservoir: A Systematic Review

BACKGROUND

An approach to the reconstruction of the ear requires consideration of gross anatomy, blood supply, and size of the defect to select the repair. While skin grafts provide a convenient option for many helical and conchal defects, using posterior auricular reservoir can preserve ear contour and hide the scar for an aesthetic closure.

PURPOSE

To illustrate the versatility of the post-auricular and mastoid skin reservoir for auricular repairs after surgical removal of a cutaneous malignancy.

DATA SOURCES

MEDLINE, EMBASE, and Cochrane Databases were searched for all techniques using a post-auricular approach for auricular repair of surgical defects in the context of cutaneous oncology until November 2019.

DATA SYNTHESIS

The most well-described techniques of pull-through, post-auricular pedicle and Banner flaps were selected for in-depth review. Illustrative cases and a summary of the spectrum of techniques from case reports are provided.

LIMITATIONS

Few randomized trials exist to compare the outcomes of the flaps to determine a preferred flap technique.

CONCLUSIONS

A post-auricular approach for repair of auricular defects can provide a reasonable option for single and multi-staged closure to create an excellent aesthetic outcome while hiding the donor site. More prospective data is required to determine the overall best approach. J Drugs Dermatol. 2020;19(9):883-888. doi:10.36849/JDD.2020.5106.

Rapid Evolution of a Squamous Cell Carcinoma In Situ to Locally Invasive With Perineural Involvement

We present a case of rapidly progressing squamous cell carcinoma in situ (SCCis) with progression to aggressive SCC. An elderly gentleman with multiple medical comorbidities presented with a left zygomatic tumor initially diagnosed as SCCis with adnexal extension on histology. After a period of approximately 10 weeks, the patient underwent Mohs micrographic surgery (MMS) with evidence that the tumor was now consistent with a well-differentiated SCC, with perineural involvement. MMS was stopped after two stages and the patient was sent to head and neck surgical oncology for further evaluation and management. It has been reported in the literature that 3&ndash;5% of SCCis will progress to invasive SCC; although the inciting event to cause such progression is unknown, it is thought that mutations in key oncogenes or tumor suppressor genes such as TP53 may play a role. In addition, as many as 31% of SCCis may have a component of invasive SCC that is missed on initial histology due to sampling bias. This case reminds us that sampling bias can occur during biopsy, SCCis can rarely progress to invasive SCC, and highly aggressive SCCs may prove to be therapeutically challenging requiring a multidisciplinary approach. J Drugs Dermatol. 2020;19(11):1110-1111. doi:10.36849/JDD.2020.5184.

A Multicenter Study to Evaluate Subject Satisfaction With Two Treatments of AbobotulinumtoxinA a Year in the Glabellar Lines

BACKGROUND

Real-world re-treatment intervals for botulinum toxins vary, but most subjects receive treatment less frequently than the manufacturer-recommended minimum intervals. In subjects receiving treatment with AbobotulinumtoxinA (ABO) less frequently, high levels of satisfaction and psychosocial improvements in well-being, self-confidence, and quality of life are observed.

OBJECTIVE

To evaluate subject satisfaction with a twice yearly re-treatment schedule.

METHODS AND MATERIALS

This open-label, multicenter, interventional study evaluated subject satisfaction following injections of ABO 50 U in the glabellar lines at baseline and 6 months. The primary end point was subject satisfaction at 12 months. Secondary endpoints included subject satisfaction, FACE-Q scales, and glabellar line severity scale (GLSS).

RESULTS

Ninety-five percent of the 120 subjects were "highly satisfied" or "satisfied" with their treatment outcomes at 12 months. FACE-Q total scores suggested that subjects were less bothered by glabellar lines and felt better about their facial appearance with each treatment versus baseline. Approximately half of subjects had ≥1-grade improvement from baseline in GLSS at 12 months. Median onset of effect was 2 days.

CONCLUSION

The majority of subjects (95%) were satisfied with ABO treatment every 6 months; results were supported by high subject satisfaction, long duration, rapid onset, natural-looking results, and overall psychological wellness and safety.

Examining the Role of Microbiota in Emotional Behavior: Antibiotic Treatment Exacerbates Anxiety in High Anxiety-Prone Male Rats

Intestinal microbiota are essential for healthy gastrointestinal function and also broadly influence brain function and behavior, in part, through changes in immune function. Gastrointestinal disorders are highly comorbid with psychiatric disorders, although biological mechanisms linking these disorders are poorly understood. The present study utilized rats bred for distinct emotional behavior phenotypes to examine relationships between emotionality, the microbiome, and immune markers. Prior work showed that Low Novelty Responder (LR) rats exhibit high levels of anxiety- and depression-related behaviors as well as myriad neurobiological differences compared to High Novelty Responders (HRs). Here, we hypothesized that the divergent HR/LR phenotypes are accompanied by changes in fecal microbiome composition. We used next-generation sequencing to assess the HR/LR microbiomes and then treated adult HR/LR males with an antibiotic cocktail to test whether it altered behavior. Given known connections between the microbiome and immune system, we also analyzed circulating cytokines and metabolic factors to determine relationships between peripheral immune markers, gut microbiome components, and behavioral measures. There were no baseline HR/LR microbiome differences, and antibiotic treatment disrupted the microbiome in both HR and LR rats. Antibiotic treatment exacerbated aspects of HR/LR behavior, increasing LRs' already high levels of anxiety-like behavior while reducing passive stress coping in both strains. Our results highlight the importance of an individual's phenotype to their response to antibiotics, contributing to the understanding of the complex interplay between gut microbes, immune function, and an individual's emotional phenotype.

Variables Affecting Basal Cell Carcinoma and Melanoma In Situ Excision Clearance: A Multi-institutional Retrospective Study

BACKGROUND

The primary endpoint for surgical excision of skin cancer is the positive margin status. Tumor characteristics may explain much of this risk, but other important factors can include physician specialty.

OBJECTIVE

To determine the variables affecting the success of a basal cell carcinoma (BCC) or melanoma in situ (MIS) excision.

METHODS/MATERIALS

An 8-year, multicenter, retrospective study of 5,800 BCC or MIS excisions performed at 13 different Kaiser Permanente medical centers. The margin status was determined by searching final pathology diagnosis texts for phrases associated with positive margins.

RESULTS

An incomplete excision rate was found in 23% of all specimens (BCC-22%, MIS-25%). Per specialty, the proportion of specimens with positive tumor margins was 24% for dermatology, 26% for plastic surgery, 28% for otolaryngology, and 12% for general surgery. General surgeons most often excised large tumors and tumors from truncal regions, 2 variables conferring lower odds of an incomplete excision. For non-Mohs procedures, dermatologists were no different than otolaryngologists or plastic surgeons in performing an incomplete BCC or MIS excision in all multivariate models (all p > .05).

CONCLUSION

Intrinsic tumor characteristics may influence the success of achieving tumor-free resection margins more than the specialty of the provider.

Aesthetic Office Disaster Preparedness and Response Plan

The coronavirus pandemic (COVID-19) has served as a call-to-arms in preparing practices for the next disaster whether it is another infectious disease or a flood, hurricane, earthquake, a sustained power outage, or something else. A group of predominantly core aesthetic physicians discussed the various aspects of their office procedures that warrant consideration in a proactive approach to the next pandemic/disaster-related event. This guide does not set a standard of practice but contains recommendations that may avoid some of the "lessons learned" with the COVID-19 pandemic. In this paper, the board-certified core aesthetic physicians classified these recommendations into four generalized areas: Practice Management; Supplies and Inventory; Office Staffing Considerations and Protocols; and Patient Management Strategies. Proactive strategies are provided in each of these categories that, if implemented, may alleviate the processes involved with an efficient office closure and reopening process including, in the case of COVID-19, methods to reduce the risk of transmission to doctors, staff, and patients. These strategies also include being prepared for emergency-related notifications of employees and patients; the acquisition of necessary equipment and supplies such as personal protective equipment; and the maintenance and accessibility of essential data and contact information for patients, vendors, financial advisors, and other pertinent entities.J Drugs Dermatol. 2021;20(1):10-16. doi:10.36849/JDD.5803.

DaxibotulinumtoxinA for Injection for the Treatment of Glabellar Lines: Efficacy Results From SAKURA 3, a Large, Open-Label, Phase 3 Safety Study

BACKGROUND

DaxibotulinumtoxinA for Injection (DAXI) is botulinum toxin Type A formulated with a novel peptide excipient. Two pivotal, single-treatment, placebo-controlled trials demonstrated efficacy and safety for moderate or severe glabellar lines.

OBJECTIVE

To further evaluate DAXI in a large, open-label, repeat-treatment study.

METHODS

Subjects (n = 2,691) were enrolled from the preceding pivotal trials or de novo and received 40U DAXI. Those who received repeat treatments could be retreated when they returned to baseline on the Investigator Global Assessment-Frown Wrinkle Severity (IGA-FWS) and Patient FWS (PFWS) scales at/after 12 weeks and up to 36 weeks after treatment.

RESULTS

High (>96%) response rates (none or mild severity) on the IGA-FWS scale were seen after each of the 3 treatments, with peak response between Weeks 2 to 4. At Week 24, ≥32% had a response of none or mild severity. Peak response rates of ≥92% were observed at Weeks 2 to 4 on the PFWS scale. The median duration for return to moderate or severe severity was 24 weeks. The safety profile was favorable and consistent with previous trials.

CONCLUSION

DaxibotulinumtoxinA for Injection efficacy was highly consistent across treatment cycles. These results confirm the previously observed efficacy rates and duration of response.