BBI Contributing Writer
NEW YORK – Duane Whitaker, MD, of the University of Iowa Hospital & Clinics (Iowa City, Iowa), the chair of this year's American Academy of Dermatology (AAD; Schaumburg, Illinois) summer meeting, held here in late July and early August, said that record attendance was due to a combination of location and content. "Academy '04 presented a well-balanced educational program featuring emerging concepts, new therapies in cosmetic dermatology, and cutting-edge industry symposia that took place in the heart of one of the most exciting cities in the world," Whitaker said.
Sculptra, the first in a new category of fillers from Dermik Laboratories (Berwyn, Pennsylvania), was high on the cosmetic radar screen at the meeting. According to William Philip Werschler, MD, of Spokane, Washington, who is one of Sculptura's clinical investigators, "injectable poly-L lactic acid represents an entirely new concept of total facial restoration that has previously been the domain of incisional plastic surgery." Used since 1999 in Europe and recently FDA-approved for medical treatment of lipoatrophy, the material is a synthetic injectable that is biocompatible and bioabsorbable and works well for hollow, gaunt cheeks; bitemporal wasting and sunken eye rings; and to restructure or sharpen the chin and jawline.
Werschler said that, similar to filling a balloon with air or adding layers to clay in 3-D, Sculptra provides volumetric enhancement, behaves much like an injectable implant or "liquid facelift" and metabolically stimulates the fibroblasts to make new collagen. The assistant clinical professor in medicine and dermatology at the University of Washington (Seattle) and president of the American Society of Cosmetic Dermatology and Aesthetic Surgery reported that Sculptra takes time to gradually correct volume loss. He reported that most patients typically require three interventions over monthly intervals, and cautioned colleagues that Sculptra is not your customary wrinkle filler.
"Results are very technique-sensitive using a threading-like injection and last significantly longer than the current collagen- or hyaluronic acid-based fillers," Werschler said. "In fact, clinical studies for Sculptra show treatment effects lasting an average of two years in most patients." He added that "with Sculptra we don't want to overcorrect, but correct to perfection. Also, we find that if we increase the dilution so the material is less concentrated, we get greater diffusion and dispersion, which significantly reduce the likelihood of micronodules or granuloma formation." Werschler offered what he termed his 5-5-5 tip: "Patients should massage the treated areas five times per day for five minutes for five days."
Broadening use of Botox
Concurrent presentations by dermatologists Arnold Klein, MD; Seth Matarasso, MD; and Patricia Wexler, MD, had attendees shuttling between two adjacent, standing-room-only courses on botulinum toxin and fillers. In live patient demonstrations by Drs. Matarasso and Wexler, the duo showed that techniques for injectables have become more like an art form involving finesse and skill than simply cookbook medicine with predetermined injection sites. Addressing the versatility of Botox Cosmetic from Allergan (Irvine, California), Matarasso remarked that in his San Francisco practice, Botox therapy has matured into an ancillary procedure combined with fillers and lasers. The professor of dermatology at the University of California, San Francisco said he favors using smaller doses of Botox to weaken, rather than paralyze, the muscles in order to create harmony and bring all segments of the aging face into optimal balance. "For instance, we increasingly use what we term 'Botox Lite' in conjunction with various fillers and laser procedures to treat the lower third of the face – the nasolabial folds, cheek buckles, around the lips and the chin area," he said. "We also use Botox Lite for mild lifting and to create symmetry in the brow area or at the corners of the mouth."
Rejuvenation of the d colletage area is another aesthetic application under consideration, but he said the subtle results may not justify the cost of treatment, especially for his Bay area patients who tend to be rather judicious.
Matarasso said smaller doses of Botox therapy also can be used to increase the longevity of filling agents by decreasing the external movement surrounding it. Similarly, he noted that he often administers Botox as an adjunct to reconstructive procedures. "For primary closure and repair of a wound following Mohs surgery, we strategically inject Botox to help the healing process and provide optimal cosmetic results," said Matarasso, who also specializes in skin cancer surgery. With respect to medical indications, he noted that Botox recently received FDA approval for treatment of hyperhidrosis or excessive sweating, a disorder that affects more than 2.8 million people in the U.S.
He added that Phase III clinical trials of Dysport, a new form of botulinum toxin Type A from Inamed (Santa Barbara, California), are under way, with the commercial product expected to be available in the near future.
Turning from Botox to botanicals, Zoe Draelos, MD, clinical associate professor of dermatology at Wake Forest University School of Medicine (Winston-Salem, North Carolina), provided an inside look at how new cosmeceuticals are identified and commercially developed, saying that "dermatologists need to be informed about anti-aging products because today's cosmetic patients are not just interested in advice on procedures but also turn to us for recommendations on skincare options." The rationale for desirable cosmeceutical technologies relies on the fact that skin sustains continuous damage from oxidation, inflammation and irritation. Thus, she said, "the search is on for actives that can function in each of these arenas with new actives most likely to be found in the plant kingdom. As a rule of thumb, products that you can eat can be assumed to be safe when applied topically to the skin."
Draelos outlined six considerations in the pursuit of new cosmeceuticals:
1) Plant source – the leaves, roots, fruits, berries, twigs, flowers, etc.
2) Growing conditions such as soil composition, climate variations and plant stress.
3) Harvesting conditions, including care of plant materials from shipping to storage prior to manufacture.
4) Preparation method – does it require crushing, grinding, boiling, distilling or pressing?
5) Final extract status – is it a liquid, powder, paste, syrup or crystal?
6) Concentration – is there sufficient amount of active to produce a biologic effect?
She provided an overview of the function and properties of each of the three categories of cosmeceuticals: antioxidants, anti-inflammatories and soothing agents or anti-irritants. Soy, curcumin and idebenone were cited among the top antioxidants; oral ginko, green tea and almond extract as popular anti-inflammatories; and aloe vera, allantoin and prickly pear as well-accepted skin soothers.
Draelos described a relatively new group of cosmeceuticals called "nutritional cosmeceutical antioxidants," which is gaining recognition and shelf space. "These products contain the common chemicals of flavones, xanthones, carotenoids and polyphenols, and their extracts are finding their way into the latest skin treatments, which happen to be dietary supplements," she reported. Other up-and-coming agents tagged for future marketing include Acetyl Hexapeptide-3, which acts like a topical muscle relaxer; and Kombuchka, a lipo-filler thought to help increase the appearance of volume. Draelos explained that by using the word "appearance," companies sidestep the FDA's purview over medical claims regarding a product's anti-aging effects on the structure or function of the skin.
Acne treatment still a hot topic
Another hot topic on the AAD program was acne treatment – from topical cosmetics to high-tech devices and photodynamic therapy (PDT). Ella Toombs, MD, director of the Aesthetic Dermatology of Dupont Circle (Washington) practice, opened her presentation on "Cosmetics in the Treatment of Acne vulgaris" by echoing current opinions about the role of today's cosmetic dermatologist. "More than any advertisement, patients respect dermatologists as the skincare specialist and look to us for specific guidance and suggestions in helping them make appropriate choices in the selection of skincare products."
When applied to the treatment of acne, Toombs advocates being "proactive in providing patients with a comprehensive regimen that avoids the use of oral antibiotics while maximizing the effectiveness of topical treatments, which ultimately increases patient satisfaction and compliance."
Toombs, a former acting director of the Office of Cosmetics and Colors at the FDA, referenced Section 201 of the Food, Drug & Cosmetics Act to define cosmetics as:
"(1) articles intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body or any part thereof for cleansing, beautifying, promoting attractiveness, or altering the appearance; and (2) articles intended for use as a component of any such articles; except that such term shall not include soap."
Evaluating the therapeutic value of various cosmetic ingredients against the pathogenesis of acne, she proposed a 20-week regimen geared to skin of color.
Week 1-7: Topical retinoids to eliminate comedones; benzyl peroxide to reduce papules; and topical antibiotics to control postules, plus use of non-irritating cleaners and moisturizers twice daily.
Week 8: Introduce a light (comedolytic) chemical peel of 30% AHA and use of an exfoliating cleanser containing astringent and peeling ingredients.
Week 12: Discontinue use of topical antibiotic and introduce mask such as sulfur, salycid acid or kaolin.
Week 16: Decrease benzoyl peroxide and introduce home chemical peels with concentration/formulation of 15% to 20% glycolic or salicylic acid.
Week 20: Taper retinoid and continue cosmetics, featuring astringent cleanser and comedolytic cleanser, mask, spot treatment of salicylic acid, sulfur or zinc, and home peels.
For those inclined to high-tech devices, Bruce Katz, MD, director of the Juva Skin and Laser Center (New York), offered a roundup on laser/light therapy for acne treatment. As a context for the growing acceptance of these techniques in clinical practice, he cited three recent developments:
– More and more women in their 30s and 40s are experiencing acne breakouts and want fast solutions without oral drugs.
– Recently published studies showing an increased incidence of breast cancer in women on long-term antibiotics.
– The controversy with isotretinoin (Accutane).
"There are several safe and effective laser and light sources for the treatment of acne and acne scarring based on wavelength and mechanism of action," said Katz, who described the roles of the various systems using blue light, green light, broadband IPL, radiofrequency energy and non-ablative lasers, including the 595 nm, 1064 nm, 1320 nm and 1450 nm, to target P. acnes and sebaceous glands.
He said combination therapy such as blue light enhanced with radiofrequency thermotherapy or use of a short-contact 5-aminolevulinic acid (ALA) plus laser/light treatment has emerged as the latest acne-fighting strategy. "The buzz in acne treatment today is laser photodynamic therapy (PDT). This new approach delivers an ALA photosensitizer – Levulan Kerastick from Dusa Pharmaceuticals (Wilmington, Massachusetts) – that is activated by the appropriate light source – IPL, pulsed dye laser or blue light," Katz noted. "The treatment works by shrinking sebaceous glands, and its key benefits are greater selectivity and high safety.""
He described the prime candidates for laser PDT as those who have been on drugs and are experiencing side effects or non-responsive acne and/or those who have full body acne. While there is more than one successful laser/light system for PDT, Katz said he liked the TriStar pulsed dye laser due to its large spot size and cooling device.
He noted that he had recently found that use of ultrasound to apply the ALA drives the photosensitizer into the skin in about 15 minutes as compared to the customary one hour. He reported that most patients find a series of six full-face treatments beneficial, with many showing significant clearing after three treatments. As a general caveat, he cautioned colleagues to reduce the parameters of ALA laser therapy when treating patients with serious sundamage.
Katz said that in addition to acne, photorejuvenation and actinic keratoses, he sees several new uses for PDT on the horizon, including rosacea, keratosis pilaris, sebaceous gland hyperplasia, hidradenitis suppurativa and nail fungus, among others. "We've just begun to tap the clinical usefulness of PDT," he said. "With additional studies and more clinical experience among a larger group of aesthetic surgeons and dermatologists, we can further refine the protocols to achieve optimal results for a variety of skin conditions."