Sunscreen smarts

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March 21, 2017

By Bob Kronemyer – Modern Medicine Network

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Do dermatologists believe that high-SPF sunscreens provide an additional margin of safety? How safe are sunscreens that contain oxybenzone? These answers and more appear in the results of a recent survey in the January edition of JAMA Dermatology.

“Multiple professional organizations, including the American Academy of Dermatology, as well as dermatologists themselves, have recommended patient counseling regarding the use of sunscreen,” write the authors from the University of Miami Miller School of Medicine in Florida. “However, there have been other conflicting messages about sunscreen (sometimes without scientific support) that have led to confusion by the public.”

Case in point, of the 156 dermatologists included in the outcome analyses, 99% believe that their patients generally do not apply sufficient sunscreen.

As for patient counseling, 97% of dermatologists indicate they are comfortable recommending sunscreens with a sun protection factor (SPF) of at least 50, and 83.3% believe that high-SPF sunscreens provide an additional margin of safety.

When recommending sunscreen, dermatologists consider several factors, including SPF level (99%), broad-spectrum protection (96%), cosmetic elegance and/or feel (71%) and photostability (42%).

As for the doctors themselves, they have good intentions, but don’t always follow through. In their own outdoor use, 100% of dermatologists select a sunscreen with an SPF of at least 30, but only 76% admit to routinely applying sunscreen more than half the time.

Other points that dermatologists agree on include:

  • Routine use of sunscreen helps lower the risk of skin cancer (97%)
  • Sunscreen reduces subsequent photoaging (100%)
  • FDA-approved sunscreens currently available in the U.S. are safe (96%)
  • Sunscreens containing oxybenzone or retinyl palmitate are safe (91% and 87%, respectively)

In addition to counseling patients, 99% of respondents also recommend that their family and friends use sunscreen.

There were no significant differences in responses based on geographic location or number of years in practice.

Global perspecitves on cosmetic fillers

Haasan I. Galadari, M.D.

With so many new and exciting filler products in the U.S. pipeline, American dermatologists and their patients are in for a treat, according to Hassan I. Galadari, M.D., who presented “Up and Coming Fillers: Experience from Across the Atlantic,” on March 4 at the 2017 American Academy of Dermatology (AAD) Annual Meeting in Orlando, Fla., March 3 through 7.

Dr. Galadari, an American board-certified dermatologist who practices in Dubai, says there are more than 80 companies that produce hyaluronic acid (HA) fillers worldwide.

“…though not all will be approved in the U.S., the larger companies–those who push the envelope in the areas of research and development–will be introducing their products to the U.S. very soon,” Dr. Galadari tells Dermatology Times.

A trend among filler companies is to focus on adding products that cater to certain parts of the face, he says.

“In the U.S., doctors are made to dilute their fillers in order for them to safely use them in certain parts of the face–say the tear troughs under the eyes, for example. That will change with the introduction of newer softer products that have been approved for those indications,” Dr. Galadari says.

Recent U.S. approvals for Restylane’s Refyne and Defyne (Galderma) fillers occurred long after the rest of the world began using those fillers. The newest Galderma HA fillers in the U.S. have been in use in other parts of the world since 2010, as part of Galderma’s Emervel line.

HA fillers are not the only potential new kids on the block. Non HA fillers will be entering the U.S. market soon. While not much has changed with poly-L-lactic acid (PLLA) and calcium hydroxylapatite (CaHA) formulations, a filler containing polycaprolactone (PCL) is in the pipeline to be approved in the U.S., according to Dr. Galadari.

“PCL is a bio-stimulatory filler that comes in four different formulations of different longevities, without affecting its viscosity and no change in extrusion forces. The longest in the range, which can last up to four years, may be used for those with structural anomalies or defects, such as HIV lipoatrophy and even acne scars,” he says.

Avoiding, addressing potential complications

Filler use is not without complications. The good news is there are ways to address and avoid them.

Swelling is one of the most common adverse filler-related effects. Different fillers—even those in the same category, such as HA—behave differently, according to Dr. Galadari.

“Depending on the concentration of short and long chain HAs in the product, the degree of swelling varies. Swelling is transient, but there are some products where the swelling can last more than two weeks, and, for patients seeking fast and immediate beautification for an event, [that might not be acceptable],” he says.

Bruising can result, especially when treatment involves many injection sites.

“Needles, potentially, can statistically cause more bruising to happen as compared to a cannula. That’s why the use of cannulas have risen. Cannulas are great tools, but their limitation may lie in the fact that they can only inject the deeper plane and not the dermis. The superficial lines need to be injected with needles,” Dr. Galadari says.

Lumps can occur with use of any product. And when they do with HA fillers, injectors can simply dissolve them by injecting hyaluronidase.

“The same cannot be said with non HA fillers, which may require the injection of saline to help soften the lump, but not essentially dissolve it. Granulomas are distinct lumps that have to be proven histopathologically,” he says.

Biofilm can occur with any product but are common with HA fillers. The only way to remove biofilm is with complete removal of the product and a course of antibiotics, according to Dr. Galadari.

“Intralesional steroid use has fallen out of favor and is not as common as in the past, given that [the steroids] may cause more harm than good in terms of causing atrophy to the surrounding tissue,” he says.

Neurovascular compromise, while not the most common adverse event, is the most alarming. Necrosis can ensue if it is not correctly identified. If that happens, the effect is usually long lasting scarring. It is important to be able to identify this as quickly as possible, according to Dr. Galadari.

“Patients may present in two different ways. The first is immediate blanching of the area where the filler is being injected. This identifies an embolism, an intravascular injection of the filler. If this occurs, then immediate cessation of injection should be done, followed by flushing of the filler with a high concentration of hyaluronidase for both HA and non HA fillers. Manual massage is important as this recruits surrounding blood vessels to the area. Warm compresses may also be applied. [Nitroglycerine] paste may also be used. Patients should be injected repeatedly with hyaluronidase every 30 to 60 minutes before leaving the clinic to ensure that circulation has been reestablished in the area. Aspirin and sildenafil have also been prescribed to be used at home as an antiplatelet and vasodilator respectively,” he says. “The other feature of impending necrosis can occur when at home. Patients usually complain of severe pain and tenderness within the first 24 hours. If patients do so, the doctor should immediately ask them to come to the clinic and the steps delineated above should be performed.”

On the horizon

Teoxane’s Teosyal Resilient Hyaluronic Acid (RHA) line will introduce one of the newer fillers to the U.S. market, according to Dr. Galadari.

“This will be distributed by Alphaeon in the US. The filler will be approved by the end 2017 or beginning of 2018,” he says. “One of the advantages of this filler is its ability to stretch in areas of dynamism, especially the mouth, but without compromising its lifting effect. The filler holds an advantage of becoming integrated to the surrounding tissue and is extremely forgiving, in the unlikely event of when a lump occurs. Preliminary work in the lips and perioral lines are very promising.”

Other newcomers to the U.S. filler market, according to Dr. Galadari, include additions to the Merz Aesthetics Belotero line, including a volumizing HA. Galderma and Allergan will also continue to introduce fillers that have been available in Europe and the rest of the world, he says.

Dr. Galadari offers these three best practices for filler use:

Choose the right patient. If you don’t have the right patient and decide to inject anyway, you will have an unsatisfied patient. Ask patients specific questions to understand their expectations and to determine whether filler injections are right for them.

Choose the right filler for the right area. It’s extremely important for doctors to understand filler properties, both physiologically and histologically. A dermatopathologist showcased the importance of this point during Dr. Galadari’s AAD session.

Some examples: If a filler with high elastic modulus, or G’, is injected in the lips or tear troughs, the filler will have a tendency to create highly undesirable lumps. The same thing can be said if the injector uses fillers with a lower G’ in the cheeks. He or she will need a huge volume to get a lifting effect, which can be quite costly for the patient. That being said, biostimulatory fillers should be avoided in general in areas of the lips and tear troughs. With the upcoming introduction of softer HA fillers , areas which were considered taboo, such as the glabellar complex, where many reported cases of necrosis have occurred in the past,  may now safely be injected provided that anatomic knowledge of the area is adequate.

“Currently, there are low-G’ HA fillers that can be safely injected in that area provided a ‘correct’ approach is undertaken to avoid pitfalls,” he says. “With the newer fillers being approved, we can now safely inject the correct filler for those anatomical spots.”

Choose the right injection technique. Recent adverse events (even blindness) resulting for cosmetic filler treatments draw attention to what can happen when injectors use inappropriate injection technique and have limited understanding of the anatomy.

Disclosure: Dr. Galadari is a speaker, faculty member or investigator for Sinclair Pharma (previously Aqtis Medical), Merz Aesthetics and TEOXANE Laboratories.

The Skinny on fat reduction, cellulite devices

Coolsculpting January 18, 2017

By Lisette Hilton – Modern Medicine Network

Devices aimed at reducing fat and ridding patients of cellulite’s unsightly bumps look magical in promotional ads, but how do dermatologists look beyond to choose the best technological arsenal for treating their patients? We asked for unplugged advice from Chapel Hill, N.C., dermatologist Sue Ellen Cox, M.D., who presented on fat reduction and cellulite devices in November at the 2016 American Society for Dermatologic Surgery (ASDS) annual meeting in New Orleans.

The reveal

There are plenty of noninvasive fat reduction devices. Nuances help differentiate them.

Dr. Cox’s noninvasive fat-reduction device of choice and the one that she has been using for about five years is CoolSculpting (Zeltiq).

The ultrasonic destruction of fat cells with UltraShape is another option. Dr. Cox did the clinical trials for UltraShape but doesn’t own the device.

“The company typically recommends three treatments to get the result that is expected or anticipated by the patient,” Dr. Cox says. “What I was seeing during the clinical trials was that it may have not been quite as predictable as what I see with the CoolSculpting, which is typically just one or two treatments for a very defined 20 percent to 25 percent reduction of fat. I can also tell you in terms of studies out there, CoolSculpting for noninvasive fat reduction really does have the most.”

Other options: Vanquish (BTL Aesthetics), a radiofrequency device for fat reduction, and the other ultrasonic device Liposonix (Valeant).

“I had the Liposonix done on my lower abdomen once and didn’t even finish the procedure it was so uncomfortable. And I was not overly impressed with the results that I was seeing in the clinical trials,” Dr. Cox says. “I had the CoolSculpting done on my lower abdomen once and upper abdomen twice with no discomfort.”

The new device on the block is SculpSure (Cynosure), which is a noninvasive laser.

“It’s a 1060 nm wavelength laser that is attracted to fat as its chromophore,” Dr. Cox says.

Dr. Cox says she thinks all these devices are good, but some work better than others.

“Some of them require more sessions, like the UltraShape or Vanquish. Even the SculpSure requires more than one treatment. When CoolSculpting first came out, they talked about it being a one and done thing, but over the years have adjusted expectations by saying there’s a ‘treatment to transformation,’ meaning that you treat an area and you’re going to get 20 to 25 percent reduction in fat. But you may want to treat it again, to get another 20 to 25 percent reduction, or work areas that are adjacent to the areas that you’ve already worked on, so you’re truly sculpting these patients,” Dr. Cox says.

Liposuction still hard to beat (track record-wise)

Though she says these numbers might have since changed, Dr. Cox did a PubMed data search in October 2015 and found there were 50 peer-reviewed articles on CoolSculpting; 37 for Liposonix; 18 for UltraShape; 16 for Vanquish; and eight for Kybella. Cynosure’s website lists three paper presented at American Society for Laser Medicine and Surgery meetings but no published articles in the peer-reviewed literature.

“But if we compare published studies to liposuction, liposuction has over 1,190 peer-reviewed articles. So, liposuction still may be the gold standard, even though that’s not what patients appear to be as interested in because it’s invasive and there’s downtime,” Dr. Cox says.

While liposuction’s appeal might wane in light of new technologies, patients who do opt for the old standby fat removal approach are generally as happy as or happier than those who have noninvasive options.

“If you look at RealSelf, and I pulled the data from 2015 and 2016, it’s across the board in terms of people saying they’re really happy with [liposuction],” Dr. Cox says. “Typically, liposuction has one of the highest ‘Worth It’ ratings and number of reviews,” she says.

For example, at last glance (December 5, 2016), liposuction had 4,561 RealSelf reviews and a 91 percent Worth It rating; UltraShape had 115 reviews and an 87 percent Worth It rating. For CoolSculpting, there were 2,630 reviews and an 83 percent Worth It rating. And Kybella had 279 reviews and 87 percent Worth It rating.

“But I do think that patients are happy with the noninvasive technology. It is pretty easy with the CoolSculpting. The nice thing is they’ve updated the device, so there is a 35-minute cycle time, as opposed to an hour. From the standpoints of patient ease and satisfaction, it’s great,” Dr. Cox says. “In terms of patients being able to return to work with any of these noninvasive devices, it’s pretty immediate. The next day, they can go back to exercising; they can go back to work. There’s really no downtime, with the exception of maybe some temporary numbness or tingling sensation.”

But patients might need multiple sessions with noninvasive devices, whereas, it’s one treatment and done with liposuction, Dr. Cox says.

“You can do several areas at once and have one downtime, one procedure, one expense,” she says.

Dr. Cox says her colleagues that offer fat reduction and removal should keep in mind that the noninvasive are becoming more and more of a commodity offered at salons, medi spas and more.

“There’s a spot near me that was only doing laser hair removal until about six months ago. Now they’re doing CoolSculpting. That’s an issue,” she says.

Making choices

Dr. Cox says colleagues should learn before they purchase or rent one of these devices.

“Definitely look at the peer-reviewed data,” she says. “That’s why I chose CoolSculpting. There is a lot of data to show it is predictable—that it results in 20 to 25 percent reduction in fat every time you’re hooked up to the device. There was recent information where there was 30 percent reduction with UltraShape, and maybe that’s 30 percent because you have to do it three times. You have to look at all this information critically,” she says.

Dermatologists who don’t hop on the noninvasive fat reduction train might miss opportunities for new patients, Dr. Cox says.

“If you don’t have the noninvasive technology, patients aren’t as likely to be driven to your door. They’re drawn to your office by what they see online or on billboards. If you don’t have the noninvasive technology, they’re less likely to come to your office and they may be a better candidate for liposuction but you might not even get to see them,” she says.

The field for noninvasive fat reduction is burgeoning.

“The demand is so high. Patients calling the office. Who doesn’t have a bulge they’d like to get better?” Dr. Cox says.

Disclosure: Dr. Cox did clinical trials for Liposonix (Valeant Pharmaceuticals), UltraShape (Syneron Candela) and Kybella (deoxycholic acid, Allergan). She is a consultant for Merz.

Zika – What You Need To Know

July 25, 2016
By Maureen S Hamel MD, Brenna L Hughes MD MSc – Modern Medicine Network

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Zika virus was first identified from the Rhesus monkey in 1947 in the Zika Forest, Uganda. The virus was subsequently isolated from humans 5 years later. Since the 1950s 3 major outbreaks have been reported: 2007 in the Yap islands of Micronesia; 2013 in French Polynesia; and most recently in 2014–2015 in Brazil. Because the symptoms of Zika are similar to several other viruses such as chikungunya and dengue fever, it is likely that cases in other regions have occurred but have not been identified.

Prior to 2007, Zika was not reported outside of Africa and Asia, and since it was first reported in Brazil in May 2015, the virus has swiftly spread across South and Central America and into the Caribbean. During this time, Brazil has seen a concomitant increase in the frequency of neonatal microcephaly. These parallel findings suggested a link between Zika and birth defects—a relationship not previously identified. With the outbreak of Zika infection and its probable link to teratogenicity has come vast media attention. Zika was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) in February 2016 and it is predicted that transmission to new countries and territories will continue during the upcoming months to years. In fact, in June 2016, the WHO took the momentous step of recommending that women living in Zika-endemic areas delay child-bearing.

Vector

Zika is transmitted to humans via the Aedes species of mosquitoes. These mosquitoes are also responsible for the transmission of dengue fever and chikungunya viruses. The Aedes mosquitoes are unique; unlike other species of mosquitoes, they are aggressive daytime biters. The primary species transmitting Zika to humans is the Aedes aegypti and the secondary species is the Aedes albopictus. The virus is transmitted during a blood meal. Both Aedes aegypti and Aedes albopictus have been found in the United States, primarily in the southeastern region. Aedes albopictus is the vastly more prevalent species (Figure 1).

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Disease features

Zika is a flavivirus, a single-stranded RNA virus. Zika virus is challenging to identify and therefore challenging to study for several reasons.

  1. First, only 1 in 5 people infected with the virus will become ill.
  2. Not only are disease symptoms usually mild, they can be identical to many other common mosquito-transmitted viruses. Because mild viral illnesses are ubiquitous in many of the regions affected with Zika, people may never realize they have been infected. In patients who do experience symptoms, these symptoms will occur between 3 and 12 days after being bitten by an infected mosquito and will last between 2 and 7 days. Symptoms include mild fever, maculopapular rash, headache, arthralgias, and myalgias. One distinctive feature of Zika is non-purulent conjunctivitis; while this complaint is also found among patients with dengue fever and chikungunya, its presentation seems to be much more common and severe in Zika cases. Zika has not been shown to cause hemorrhagic fever, and disease requiring hospitalization and/or resulting in death is rare. As in the case of other viral illnesses, once infected, individuals are protected from future infection.

Infection prevention

The most effective methods of disease prevention are to protect against mosquito bites and to reduce opportunities for vector proliferation. The Centers for Disease Control (CDC) has recommended long-sleeved shirts and long pants in Zika-infected regions both in the daytime and at dusk. Mosquito bed nets are essential if air conditioning or screens are unavailable. The CDC also recommends the application of Environmental Protection Agency (EPA)-approved repellents to skin and clothing. These products include DEET (N,N-Diethyl-meta-toluamide) and premethrin. DEET-containing products are recommended for skin application and provide the longest-lasting skin protection. Premethrin should be used on clothing and netting. Products approved by the EPA are not expected to cause adverse health effects and are safe in pregnancy. In fact, reports have suggested it may soon be possible in some states to receive Medicare/Medicaid for DEET products. Finally, vector reduction is essential for disease pre vention. The CDC has advised state and local governments to urge residents to reduce standing water by eliminating old tires, old barrels, and other vessels for standing water. An initiative has begun to treat standing water and wetlands with larvicides such as the bacterial insecticide Bti (Bacillus thurengiensis israeliensis).

Transmission

Although Zika was discovered more than 60 years ago, because adverse pregnancy or birth outcomes have never been previously reported, research into perinatal infection and perinatal transmission is limited and ongoing. Two theories of perinatal transmission exist. The first is transplacental transmission. This theory proposes that virus is transferred directly from the mother to the fetus via the placenta. Once infected, the fetus suffers neural damage as a direct result of the virus. The other theory is one of placental inflammation, which proposes that maternal viral infection creates a placental inflammatory response. This response in turn results in fetal neural damage. The former theory is similar to other documented models of viral transmission and poor outcomes and is the more widely accepted view.

Zika can be sexually transmitted from men to their sexual partners and the possibility of male-to-female sexual transmission with subsequent fetal transmission raises concern. The first documented case of sexual transmission occurred in 2008; this was male-to-female with the sexual contact occurring a few days before the onset of symptoms in the man. With regard to the current outbreak, the first report of sexual transmission was in February 2016. However, as of March 2016, 6 cases of sexual transmission of Zika from men to their sexual partners had been confirmed in the United States. All cases of sexual transmission have been from a man to his sexual partner via vaginal, anal, or oral sex and the sexual contact has occurred before, during, or soon after resolution of symptoms consistent with Zika infection. One recent report out of New York City suggests the first case of female-to-male transmission, however it remains under investigation and it is currently unknown whether asymptomatic men can transmit virus to their sexual partners.

The duration of Zika within the male genitourinary tract is unclear and the process of viral shedding within the genitourinary system is not well understood. As such, Zika testing for the sole purpose of assessing the risk of sexual transmission is not recommended. Because of the risks of transmission from men to women and particularly the risk to the fetus during pregnancy, the CDC has set forth guidelines regarding sexual activity (see bellow)

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Two cases of peripartum transmission (ie, transmission at delivery or in the immediate postpartum period) from mother to infant have been reported; both cases resulted in mild disease for the mothers and neonates and no long-term morbidity. While viral particles have been detected in breast milk, breastfeeding has yet to be documented as a mode of transmission. Likewise, infection status after blood transfusion has yet to be reported; however, it is expected, as Zika was found in 2.8% of donors during the 2013 French Polynesian outbreak.

In June 2016, the NEJM published the first report of an affected fetus in the United States. Driggers et al. describe the case of a 33-year-old woman who traveled to Guatemala, Mexico, and Belize during her 11th week of pregnancy. A day after her return to the United States she developed symptoms of a viral infection including rash, mild fever, myalgia, and ocular pain. Her partner had similar symptoms. Serologic testing was positive for both IgM and IgG antibodies against Zika, consistent with Zika infection. Fetal ultrasounds after symptom resolution were negative for intracranial pathology. At 19 weeks, a detailed ultrasound demonstrated brain abnormalities such as bilateral frontal horn enlargement, upward displacement of the third ventricle, absence of the cavum septum pellucidum, and a decrease in head circumference from the 47th to the 24th percentile for gestational age. Fetal MRI confirmed abnormalities of the lateral ventricles, the third ventricle, and the corpus collosum. The patient elected for termination at 21 weeks’ gestation. Postmortem examination of the fetus confirmed the presence of Zika in the amniotic fluid, placenta, fetal brain, muscle, liver, lung, and spleen.

The research regarding perinatal Zika infection, while at times compelling, is limited. And many questions remain. The challenge for patients as well as practitioners is facing the unknown. The true incidence of Zika among pregnant women is unclear, as is the rate of vertical transmission. In turn, among fetuses to whom the virus is transmitted, the rate and range of clinical manifestations cannot be predicted. Indeed it seems there is a delay between maternal exposure, fetal transmission, and ultrasonographically detectable abnormalities, but this time course is not well understood. The case by Driggers et al. demonstrates that fetal abnormalities may not be seen for up to 9 weeks after maternal exposure.

Finally, and perhaps most distressing to expectant mothers, is the unknown prognosis for infants born with Zika infection. Using data from the current outbreak in Bahia as well the previous outbreaks in Micronesia and French Polynesia as models, Johansson and others estimate the risk of microcephaly among infants of mothers infected by Zika to be between 0.9% and 13%. While this estimate is concerning, it must be considered with caution as it is based on modeling and limited retrospective data. Likewise, microcephaly is only one of several potentially adverse outcomes. It is well established that infants with severe microcephaly from other causes will experience a range of neurologic sequelae, but it is unclear if this is true for all cases of Zika-related microcephaly. Neurologic problems can range from intellectual disability to sensory deficits to seizures; they can be mild, severe, or life-threatening. Long-term outcomes are not at all clear and will not be for years to come.

Countries where pregnant women are advised not to travel:

  • American Samoa
  • Argentina
  • Aruba
  • Bahamas
  • Barbados
  • Belize
  • Bolivia
  • Bonaire
  • Brazil
  • Cape Verde
  • Caribbean
  • Chile
  • Colombia
  • Costa Rica
  • Curacao
  • Dominican Republic
  • Ecuador
  • El Salvador
  • French Guiana
  • Guadeloupe
  • Guatemala
  • Haiti
  • Honduras
  • Jamaica
  • Martinique
  • Mexico
  • Nicaragua
  • Panama
  • Paraguay
  • Peru
  • Puerto Rico
  • Samoa
  • Saint Martin
  • Suriname
  • Tonga
  • U.S. Virgin Islands
  • Uruguay
  • Venezuela

Common pediatric disorders in skin of color

SkinColor2

August 10, 2016
By Lisette Hilton / Dermatology Times

While pediatric atopic dermatitis and acne have some similarities among skin of color and lighter-skin children, there are important differences when these common skin conditions affect darker skin types, according to Nanette Silverberg, M.D., clinical professor of dermatology and pediatrics, Icahn School of Medicine at Mount Sinai and chief, pediatric dermatology, Mount Sinai Health System.

Starting with eczema

Atopic dermatitis is the most common skin condition of childhood and affects about 25 percent of children in the U.S., according to Dr. Silverberg, who presented on the topic at The Skin of Color Seminar Series, held earlier this year in New York City.

“In particular, there have been studies that have shown atopic dermatitis is more common in children of African American descent or of Afro-Caribbean descent,” she says. “It certainly represents a very concerning issue in children of color.”

Differences in atopic dermatitis can occur in the presentation and severity among children of color.

“In somebody who is very light skinned, eczema is going to be red. But in children of color, we see much less erythema. We see much more in the way of lichenification, or thickening of the skin, and more follicular prominence. These are particularly vexing types of eczema, in that the lichenification, or lichenoid, type of dermatitis is often very thick and very itchy. And the follicular type can be quite deceptive. You don’t see redness. You don’t necessarily see thick or oozing skin, but it is incredibly itchy and it significantly affects children psychologically,” Dr. Silverberg says.

One of the major issues with treating children of color is that there are differences biologically, in terms of the basis of atopic dermatitis, according to the dermatologist.

In African American children, it has been demonstrated that there are reductions in ceramide content, and that could be the reason the skin barrier is not working as effectively as it should be. In children who are Caucasian of European descent, eczema is more associated with a filaggrin defect, she says.

“Filaggrin defects, particularly in Asian children, are somewhat different than those noted in Caucasian children, so we know there are some reasons biologically that the kids may be a little different,” Dr. Silverberg says.

As a result, dermatologists treating children of color who have eczema often need to use thicker emollients, including emollients that might have extra ceramide content or extra balanced fat content to enhance the skin barrier.

“We’re still moving forward to see whether the biologic basis of eczema affects how children respond to treatment. In atopic dermatitis, many of the kids with atopic dermatitis will manifest in early childhood with a lot of hypopigmentation or lightness of the skin. So, pigmentary alterations, which we see in kids of color, are temporary but are sometimes very noticeable and can concern parents,” Dr. Silverberg says. “But this generally resolves, and that’s something we can reassure parents about.”

Acne

Acne is common and comes with different concerns in children with skin of color.

“Whereas many of our Caucasian patients talk about the actual pimple lesions, most of our African American patients and many of our Hispanic and Asian patients will obsess over post-inflammatory pigmentary alterations after their acne clears,” Dr. Silverberg says. “So, there’s a focus in the skin of color acne patients, even in the teenagers, on specifically pigmentation issues.”

Hispanic pediatric patients tend to have the most severe acne types among children of skin of color, Dr. Silverberg says.

“We don’t see as much in the way of cystic acne in African American patients, historically and in the literature,” she says. “So, the population that we tend to focus on for more severe treatment or treatment, like isotretinoin, are usually Hispanic teenagers. It’s an important consideration because they have some tendency to have the cystic component, although you can see it in everybody, it seems to be the most concerning amongst that population in the teenage years.”

Dermatologists treating these children need to pay special attention to communicating the need for using good sun protection to enhance pigmentation returning properly. It’s also important to work with patients to develop a skincare regimen that’s effective both at clearing current lesions and preventing new lesions, so the pigmentation improves over time, according to Dr. Silverberg.

“There are some wonderful new acne guidelines that have come out recently from the American Academy of Dermatology … saying it’s clear that most patients of color will respond quite nicely to the products we have available, including topical retinoids … as well as azelaic acid, which has been demonstrated to be beneficial in improving both tone and skin lesions,” she says.

Study shows poor skin cancer survival in patients with skin of color

Dermatologist urges everyone to be aware of their risk and take steps toward prevention, detection
SCHAUMBURG, Ill. – July 28, 2016

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 Because Caucasians have a higher skin cancer risk than the general population, people with skin of color may believe that they don’t need to be concerned about this disease — but new research reveals this to be a dangerous misconception.

According to a study published online in the Journal of the American Academy of Dermatology on July 28, although melanoma incidence is higher in Caucasians, patients with skin of color are less likely to survive the disease.

“Everyone is at risk for skin cancer, regardless of race,” says board-certified dermatologist Jeremy S. Bordeaux, MD, MPH, FAAD, one of the study authors. “Patients with skin of color may believe they aren’t at risk, but that is not the case — and when they do get skin cancer, it may be especially deadly.”

Researchers at Case Western Reserve University in Cleveland utilized the National Cancer Institute’s Surveillance, Epidemiology and End Results database to study nearly 97,000 patients diagnosed with melanoma, the deadliest form of skin cancer, from 1992 to 2009. Although Caucasian patients had the highest melanoma incidence rate, they also had the best overall survival rate, followed by Hispanic patients and patients in the Asian American/Native American/Pacific Islander group.

African-American patients had the worst overall survival rate, and they were also the group most likely to be diagnosed with melanoma in its later stages, when the disease is more difficult to treat. According to the study, however, the timing of the diagnosis is not the only factor that affects this group’s survival rates, as African-American patients had the worst prognosis for every stage of melanoma.

Dr. Bordeaux says these differences in survival rates may be due to disparities in the timeliness of melanoma detection and treatment among different races; for example, patients with skin of color may not seek medical attention for irregular spots on their skin because they don’t believe these lesions pose a risk. Additionally, he says, there may be biologic differences in melanoma among patients with skin of color, resulting in more aggressive disease in these patients. More research is necessary to determine why survival rates differ among different ethnic groups, he says, but in the meantime, patients of with skin of color should be aware of their skin cancer risk.

“Because skin cancer can affect anyone, everyone should be proactive about skin cancer prevention and detection,” Dr. Bordeaux says. “Don’t let this potentially deadly disease sneak up on you because you don’t think it can happen to you.”

Ultraviolet radiation exposure is the most preventable skin cancer risk factor, Dr. Bordeaux says, so everyone, regardless of skin color, should take steps to protect themselves from the sun’s harmful UV rays. The American Academy of Dermatology recommends seeking shade, wearing protective clothing, and using a broad-spectrum, water-resistant sunscreen with an SPF of 30 or higher.

Although sun protection is important for everyone, Dr. Bordeaux says, people with skin of color are prone to skin cancer in areas that aren’t commonly exposed to the sun, including the palms of the hands and the soles of the feet. He says these individuals should be especially careful to examine hard-to-see areas when monitoring their skin for signs of skin cancer, asking a partner to help if necessary.

“Skin cancer is most treatable when detected early, so everyone should regularly examine their skin for new or suspicious spots,” Dr. Bordeaux says. “If you notice any spots that are different from the others, or anything changing, itching or bleeding on your skin, make an appointment to see a board-certified dermatologist.”

Cellulite: An Illness of Modernity

By Liondale | May 24, 2016

Today, cellulite plagues 90% of American women – but there are tribes with women completely free of cellulite, even at age 60 with multiple children. What is cellulite, and why do some cultures have more or less of it? Is it a modern problem? Learn the history, causes, and cures for cellulite in this article:

The History of Cellulite

To this day, no historians, anthropologists, or physicians are certain of the origins of cellulite. However, there is scant evidence for it existing much before the past 150 years in a majority of the female population. Ancient medical texts, literature, and artwork all depict women with smooth skin and no blemishes.

Before the 20th-century cellulite only appeared sparsely in art depicting thick goddesses or women of high social status. Overall, the majority of women in art and photography, until recently, were cellulite free. In the 1920s, American Photographer Arthur Albert took 4,000 photographs of women of varying body types, and those images also reveal that the women of that time period had little to no cellulite.

woman_cellulite

This may incline one to believe that simply diet and exercise are the main culprits, which is candidly not the case. Overweight women of the past often were without cellulite, as seen in Arthur Albert’s photographs. Respectively, today many women of healthy weight and even athletic women often have cellulite.

What is Cellulite?

This may incline one to believe that simply diet and exercise are the main culprits, which is candidly not the case. Overweight women of the past often were without cellulite, as seen in Arthur Albert’s photographs. Respectively, today many women of healthy weight and even athletic women often have cellulite.

modern-competitive-swimmer-with-cellulite

It is also a myth that cellulite is merely fat: we now know that cellulite is the abnormal appearance of fat cells caused by poor circulation and lymph drainage, resulting in the degeneration of connective tissues that hold fat and skin cells in the normal position.

Tribes Without Cellulite in the Modern World

There are populations that exist today with virtually no cellulite. One example is the indigenous Shipibo women of Peru, who exhibit no cellulite even past age 60 or after childbirth.

Some important differences in the lifestyles of the Shipibo and western women include lifestyle and diet. These women do not lead a sedentary lifestyle: they are active most of the day, and they eat nearly all-organic diets high in yam and yucca. Plants in the yam and yucca family contain plenty of phytoestrogens, which mimic the effects of naturally occurring estrogen in the body. Decreasing estrogen levels are known to damage the integrity of the skin, and this is how cellulite is formed; this is also why many American women experience an increase in cellulite after menopause.

Shipibo-woman-without-cellulite

Vitamins and Deficiencies

In addition, with their diverse diets, they get on average more vitamin A, C, and magnesium, which are crucial in maintaining skin health4. These vitamins have been studied extensively for their role in wrinkle reduction and for their anti-aging properties but are rarely studied in their effect on cellulite. This is likely due to the general lack of understanding surrounding cellulite: that cellulite is actually a result of the degeneration of connective skin tissues.1

Additionally, these indigenous tribes’ diets are higher in vitamins due to their agriculture practices. Pesticides, monocultures, and other poor land practices used by the majority of America’s agriculture cause a decrease in the nutrients in crops and soil. Americans are deficient in many of the essential nutrients that prevent and reduce cellulite.

In fact, vitamin deficiencies in America are staggering. According to the United States Department of Agriculture:

  • only 46% of the population consumes adequate levels of vitamin A
  • only 51% have sufficient vitamin C intake
  • Only 43% of all Americans ingest adequate levels of magnesium,which is a mineral vital to over 300 bodily functions including the collagen synthesis process7

Why do American women have more cellulite?

Causes of Cellulite

It is possible that the increase in meat and processed food consumption lead to diets with fewer vegetables, therefore leading to critical deficiencies as discussed above. Since 1961, meat consumption has been on the rise in Americans who consume twice as much meat as Europeans.

Worse, meat in the United States comes from animals commonly fed with hormones. Consuming this meat can cause hormone imbalances  which is another cause of cellulite. This is also why, as mentioned above, it can help to increase consumption of phytoestrogen-rich foods such as yam and yucca.

Another cause of cellulite could be due to the fact that modern agricultural practices in the United States: with the increase in pesticide use and the depletion of nutrients in the soil from poor land practices, it takes more of a particular vegetable to get the same nutritional benefits that previous generations received.

Also, nearly all food consumed by South American tribes who exhibit no cellulite is organic. Studies have proven that organic food has significantly higher levels of vitamins, particularly vitamin C and magnesium.

In conclusion, these tribes not only have a high vitamin diet due to the different organic foods they consume but also the vegetables they are consuming are of higher quality than their western counterparts through their farming practices.

lettuce-monoculture-organic_0

Sedentary lives

Finally, Americans’ lives are far more sedentary than these indigenous tribes. The Shipibo women are physically active all day working in fields, caring for children, walking, and maintaining their households. Technology and modern appliances that help with workloads are non-existent and therefore the Shipibo women are much more active that their American counterparts.

So, proper diet and exercise are known to help prevent cellulite (though, it cannot reduce or eliminate cellulite after it has occured).

Yes: Cellulite is a Modern Problem, But One that We Can Cure

Cellulite is relatively modern medical condition, but because of this, we understand better than ever how to prevent and treat cellulite.

A few ways to start reducing cellulite on your own include:

  • Increasing your vitamin A and C intake, as well as your magnesium consumption. Sweet Potatoes, red peppers, and spinach have the highest levels of vitamins A, C, and magnesium respectively
  • When buying vegetables, keep in mind organic options will have significantly higher levels of beneficial vitamins
  • Exercising, like diet, is always a beneficial activity. Strength training in particular that targets the legs and glutes are ideal for combating cellulite (a few exercise ideas can be found here)
  • Consume more foods with phytoestrogens, such as yucca or yams
  • Another important factor to check is your hormone levels. Hormone imbalances can certainly cause cellulite, but also a host of other serious symptoms including hypothyroidism, fatigue, and fibrocystic breast. Schedule a visit with your doctor to be sure your estrogen levels are where they should be

To discuss your Cellulite Chicago treatment with a Board Certified Dermatologist or a Licensed Healthcare Professional please make an online appointment or call 773-281-9200 today.

To view the source article on LIONDALE click here.

MiraDry: No more excessive sweat with new procedure

by FOX29PHILADELPHIA (WTXF)
Posted: Apr 28 2016 10:59PM EDT   Updated: Apr 28 2016 10:59PM EDT

We all do it. Some of us more than others.

Sweating’s a natural thing, but excessive sweating can be embarrassing and even stop you from living your life to its fullest.

Now, there’s a way to ditch your deodorants and your antiperspirants, for good.

Sweating is just part of being human, regulating your body’s temperature and keeping you cool. But, for some people it gets in the way of everyday life.

“I’ve tried everything from Drysol which is a prescription antiperspirant which really irritates the skin. It’s not so fun. It works. I’ve also tried Botox which is great and works but is temporary,” Christine Sharkey explained.

Christine has pulled out all the stops to just stop sweating.
“Once I hit puberty I felt like I always sweat a little too much,” Christine added.
“For the longest time, Botox was our only real good treatment for excessive sweating. But that was needles in the underarms. Some people would get needles in their hands if they were sweating,” plastic surgeon Dr. Louis Bucky said, “And you had to do it over and over again.” “And you had to do it over all over again.”

Enter MiraDry. One and done technology.

Dr. Louis Bucky says 80% of people can trash their deodorants and antiperspirants after just one treatment.
“We’re selectively microwaving the sweat glands—heating them up to a point where they’re not functional anymore,” Dr. Bucky explained.

Lidocaine injections numb the area while a template maps it out so the energy targets each spot precisely, with no overlap, and nothing missed. It takes about 30 minutes a side, and for women especially, this comes with one big extra. No more hair. It’s a two-fer.

Dr. Jonas Nelson is a University of Pennsylvania plastic surgery resident who just underwent the procedure. He’s one of the 20% that might have to do it twice to completely eradicate his underarm sweat.

“Just targeting those glands that tend to sweat a little bit more than others when you’re not working out or your just doing your normal everyday activities just really makes sense,” Dr. Nelson said, “You’re just going to sweat normally everywhere else and not sweat in those under arm areas.”

“We get responses back like ‘You’ve changed my life. Game changer, you know? And it’s very rewarding,” Dr. Bucky explained.

“To not worry about ‘Oh do I have deodorant with me?’ Or, you know, kind of always checking. It’s great,” added Christine.

Source: FOX 29
http://www.fox29.com/news/134291512-story

Is There A Replacement Skin In Our Future? (2)

By Lisette Hilton – Dermatology Times

Smart skin that acts like the real thing

Using household items, engineers in Saudi Arabia have created a recyclable paper-based smart skin, capable of detecting temperature, humidity, pH, pressure, touch, flow, motion and proximity at 13 cm, according to a new study in Advanced Materials Technologies.

The study’s senior and corresponding author Muhammad Mustafa Hussain, Ph.D., says this is the first time a singular platform shows multi-sensory functionalities close to that of natural skin.

A model of a paper skin with an array of 6 x 6 sensors which can sense pressure, proximity, temperature, strain, pH, flow and humidity. This sensor array is made with recyclable household materials. Photo: Muhammad Mustafa Hussain, Ph.D.

A model of a paper skin with an array of 6 x 6 sensors which can sense pressure, proximity, temperature, strain, pH, flow and humidity. This sensor array is made with recyclable household materials.
Photo: Muhammad Mustafa Hussain, Ph.D.

Dr. Hussain, associate professor of the electrical engineering, King Abdullah University of Science and Technology (KAUST) in Thuwal, Saudi Arabia, tells Dermatology Times that the development of artificial skin is an important goal in skin care, especially for wounded war, vehicle injury and acid victims. Since skin is mesoporous and covers a larger surface area, the artificial technology needs not only necessary sensory capabilities, but also should be made from affordable materials and by appropriate electronic device engineering to integrate sensory functionalities.

“In that sense, our demonstration shows the proper integration strategy for multi-sensory skin type platform creation, which can sense simultaneously and in an affordable manner,” Dr. Hussain says. “I believe that there will be more advent in this area based on our work and, soon enough, artificial skin mimicking natural skin will be developed, which can be connected to our neural system. Dermatologists can guide us (engineers) to innovate and to develop right ‘skin.’”

They made the smart skin from recyclable materials, including aluminum foil, carbon paper, sponge and more—materials manufactured cheaply and at high volumes, according to Dr. Hussain.

“The integrated strategy we have developed can make an absolutely manufactureable version [of the smart skin] in two years,” Dr. Hussain says. “A major challenge would be neural connectivity …. We also envision and have been working on adding capabilities like drug delivery in this ‘skin’ which can personalize medication.”

Is There A New Skin In Our Future? (1)

Anne Trafton | MIT News Office

 

Scientists at MIT, Massachusetts General Hospital, Living Proof, and Olivo Labs have developed a new material that can temporarily protect and tighten skin, and smooth wrinkles. With further development, it could also be used to deliver drugs to help treat skin conditions such as eczema and other types of dermatitis.

The material, a silicone-based polymer that could be applied on the skin as a thin, imperceptible coating, mimics the mechanical and elastic properties of healthy, youthful skin. In tests with human subjects, the researchers found that the material was able to reshape “eye bags” under the lower eyelids and also enhance skin hydration. This type of “second skin” could also be adapted to provide long-lasting ultraviolet protection, the researchers say.

“It’s an invisible layer that can provide a barrier, provide cosmetic improvement, and potentially deliver a drug locally to the area that’s being treated. Those three things together could really make it ideal for use in humans,” says Daniel Anderson, an associate professor in MIT’s Department of Chemical Engineering and a member of MIT’s Koch Institute for Integrative Cancer Research and Institute for Medical Engineering and Science (IMES).

Anderson is one of the authors of a paper describing the polymer in the May 9 online issue of Nature Materials. Robert Langer, the David H. Koch Institute Professor at MIT and a member of the Koch Institute, is the paper’s senior author, and the paper’s lead author is Betty Yu SM ’98, ScD ’02, former vice president at Living Proof. Langer and Anderson are co-founders of Living Proof and Olivo Labs, and Yu earned her master’s and doctorate at MIT.

Scientists at MIT and elsewhere have developed a new material that can temporarily protect 
and tighten skin, and smooth wrinkles. With further development, it could also be used 
to deliver drugs to help treat various skin conditions.

Video: Melanie Gonick/MIT

Mimicking skin

As skin ages, it becomes less firm and less elastic — problems that can be exacerbated by sun exposure. This impairs skin’s ability to protect against extreme temperatures, toxins, microorganisms, radiation, and injury. About 10 years ago, the research team set out to develop a protective coating that could restore the properties of healthy skin, for both medical and cosmetic applications.

“We started thinking about how we might be able to control the properties of skin by coating it with polymers that would impart beneficial effects,” Anderson says. “We also wanted it to be invisible and comfortable.”

The researchers created a library of more than 100 possible polymers, all of which contained a chemical structure known as siloxane — a chain of alternating atoms of silicon and oxygen. These polymers can be assembled into a network arrangement known as a cross-linked polymer layer (XPL). The researchers then tested the materials in search of one that would best mimic the appearance, strength, and elasticity of healthy skin.

“It has to have the right optical properties, otherwise it won’t look good, and it has to have the right mechanical properties, otherwise it won’t have the right strength and it won’t perform correctly,” Langer says.

The best-performing material has elastic properties very similar to those of skin. In laboratory tests, it easily returned to its original state after being stretched more than 250 percent (natural skin can be elongated about 180 percent). In laboratory tests, the novel XPL’s elasticity was much better than that of two other types of wound dressings now used on skin — silicone gel sheets and polyurethane films.

“Creating a material that behaves like skin is very difficult,” says Barbara Gilchrest, a dermatologist at MGH and an author of the paper. “Many people have tried to do this, and the materials that have been available up until this have not had the properties of being flexible, comfortable, nonirritating, and able to conform to the movement of the skin and return to its original shape.”

The XPL is currently delivered in a two-step process. First, polysiloxane components are applied to the skin, followed by a platinum catalyst that induces the polymer to form a strong cross-linked film that remains on the skin for up to 24 hours. This catalyst has to be added after the polymer is applied because after this step the material becomes too stiff to spread. Both layers are applied as creams or ointments, and once spread onto the skin, XPL becomes essentially invisible.

High performance

The researchers performed several studies in humans to test the material’s safety and effectiveness. In one study, the XPL was applied to the under-eye area where “eye bags” often form as skin ages. These eye bags are caused by protrusion of the fat pad underlying the skin of the lower lid. When the material was applied, it applied a steady compressive force that tightened the skin, an effect that lasted for about 24 hours.

In another study, the XPL was applied to forearm skin to test its elasticity. When the XPL-treated skin was distended with a suction cup, it returned to its original position faster than untreated skin.

The researchers also tested the material’s ability to prevent water loss from dry skin. Two hours after application, skin treated with the novel XPL suffered much less water loss than skin treated with a high-end commercial moisturizer. Skin coated with petrolatum was as effective as XPL in tests done two hours after treatment, but after 24 hours, skin treated with XPL had retained much more water. None of the study participants reported any irritation from wearing XPL.

“I think it has great potential for both cosmetic and noncosmetic applications, especially if you could incorporate antimicrobial agents or medications,” says Thahn Nga Tran, a dermatologist and instructor at Harvard Medical School, who was not involved in the research.

Living Proof has spun out the XPL technology to Olivo Laboratories, LLC, a new startup formed to focus on the further development of the XPL technology. Initially, Olivo’s team will focus on medical applications of the technology for treating skin conditions such as dermatitis.

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