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Background Letibotulinumtoxin A (Hugel, Inc., Chuncheon, Republic of Korea and CROMA Pharma, Leobendorf, Austria) is a newly manufactured neurotoxin derived from Clostridium botulinum strain CBFC26. Objectives The aim of this study was to assess the efficacy and safety of letibotulinumtoxin A in reducing glabellar line severity (GLS) and to evaluate long-term safety and efficacy following repeated injections. Methods In this prospective, randomized, parallel-group, double-blind, multicentre, placebo-controlled Phase III clinical trial, 355 subjects with moderate to severe glabella frown lines received injections of 20 U of letibotulinumtoxin A or placebo. GLS, onset and duration of effect, time to retreatment, and adverse events were evaluated. Response to treatment was defined as a GLS score of 0 or 1 (assessed by the subject and the investigator) and an improvement at Week 4 of ≥2 points in GLS score relative to baseline. Results At 4 weeks, 78.6% of the active treatment subjects were responders based on the investigator’s assessment and 68.8% based on the subject’s assessment, resulting in a composite responder rate of 64.7% for the active treatment group, whereas the corresponding rate was 0.0% in the placebo group (P Conclusions Letibotulinumtoxin A demonstrates high efficacy and a convincing safety profile in the treatment of glabellar lines. Level of Evidence: 2

Background Androgenetic alopecia (AGA) is the most common form of hair loss consisting of a characteristic receding frontal hairline in men and diffuse hair thinning in women, with frontal hairline retention, and can impact an individual's quality of life. The condition is primarily mediated by 5-alpha-reductase and dihydrotestosterone (DHT) which causes hair follicles to undergo miniaturization and shortening of successive anagen cycles. Although a variety of medical, surgical, light-based and nutraceutical treatment options are available to slow or reverse the progression of AGA, it can be challenging to select appropriate therapies for this chronic condition. Aims To highlight treatment options for androgenetic alopecia taking into consideration the efficacy, side effect profiles, practicality of treatment (compliance), and costs to help clinicians offer ethically appropriate treatment regimens to their patients. Materials and methods A literature search was conducted using electronic databases (Medline, PubMed, Embase, CINAHL, EBSCO) and textbooks, in addition to the authors' and other practitioners' clinical experiences in treating androgenetic alopecia, and the findings are presented here. Results Although topical minoxidil, oral finasteride, and low-level light therapy are the only FDA-approved therapies to treat AGA, they are just a fraction of the treatment options available, including other oral and topical modalities, hormonal therapies, nutraceuticals, PRP and exosome treatments, and hair transplantation. Discussion Androgenetic alopecia therapy remains challenging as treatment selection involves ethical, evidence-based decision-making and consideration of each individual patient's needs, compliance, budget, extent of hair loss, and aesthetic goals, independent of potential financial benefits to the practitioners.

Background Botulinum toxin A (BoNT-A) has grown tremendously in aesthetic dermatology since 2002 when the United States Food and Drug Administration (FDA) first approved its use for treating moderate-to-severe glabellar lines. Blepharoptosis, due to local spread of toxin, is a reported side effect of BoNT-A which, although rare, more frequently occurs among inexperienced practitioners. Objectives The purpose of this review is to highlight the causes and management of eyelid ptosis secondary to BoNT-A administration including new anatomic pathways for BoNT-A spread from the brow area to the levator palpebrae superioris muscle. Methods A literature search was conducted using electronic databases (PubMed, Science Direct, MEDLINE, Embase, CINAHL, EBSCO) regarding eyelid anatomy and the underlying pathogenesis, presentation, prevention, and treatment of eyelid ptosis secondary to BoNT-A. Anatomic dissection has been performed to assess the role of neurovascular pedicles and supraorbital foramen anatomic variations. Results Blepharoptosis occurs due to weakness of the levator palpebrae superioris muscle. Mean onset is 3-14 days after injection and eventually self-resolves after the paralytic effect of BoNT-A wanes. Administration of medications, such as oxymetazoline hydrochloride or apraclonidine hydrochloride eye drops, anticholinesterase agents, or transdermal BoNT-A injections to the pre-tarsal orbicularis, can at least partially reverse eyelid ptosis. Anatomic study shows that a supraorbital foramen may be present in some patients and constitutes a shortcut from the brow area directly into the orbital roof, following the supraorbital neurovascular pedicle. Conclusion Providers should understand the anatomy and be aware of the causes and treatment for blepharoptosis when injecting BoNT-A for the reduction of facial wrinkles. Thorough anatomic knowledge of the supraorbital area and orbital roof is paramount to preventing incorrect injection into "danger zones," which increase the risk of eyelid ptosis.

Keloid and hypertrophic scars are fibroproliferative disorders resulting from abnormal wound healing in genetically susceptible individuals. Current therapies are often ineffective. Kynurenine shows promise as a topical treatment for keloids and hypertrophic scars. In this study, healthy adult male and female subjects seeking treatment for mature keloid scars were enrolled. Subjects were randomized in double-blind fashion to receive kynurenic acid 0.5% (FS2) cream (Group 1), an active onion extract comparator treatment (Group 2), or the inactive vehicle (Group 3). Each treatment was applied twice-daily. Qualitative assessments were made using the Vancouver Scar Scale (VSS), as well as the Patient and Observer Scar Assessment Scales (POSAS). Among subjects in Group 1, there was a substantial decrease in mean PGSS scores after 30 days of treatment that continued to trend downward, becoming significant versus Group 2 at days 90 and 180 (Plt;0.05) and versus Group 3 at day 180 (Plt;0.01). Based on mean VSS scores, subjects in Group 1 achieved beneficial effects that became significant versus Group 2 at day 90 (Plt;0.01), day 120 (Plt;0.05), and day 180 (Plt;0.001) and versus Group 3 at day 180 (Plt;0.05). There were no significant improvements in Groups 2 or 3. There were no adverse events or local skin reactions. The twice-daily application of FS2 Cream represents a potentially new and effective treatment for mature keloid scars. J Drugs Dermatol. 2021;20(9):964-968. doi:10.36849/JDD.6197.

Background The literature on botulinum neurotoxin type A (BoNT‐A) is extensive, often contradictory, and confounded by a competitive market of products and research attempting to distinguish brand individuality. Methods A comprehensive review of literature on the principles of BoNT‐A in aesthetics as well as clinical examples. Results In 2017, the Eight Key Clinical Postulates were formulated as a guide for the aesthetic practitioner in understanding BoNT‐A pharmacodynamics and to compare different toxins. These are now updated to include (a) All type A toxins act identically; (b) The mathematical relationship between toxin and receptor is the basis of efficacy, and clinical efficacy is influenced by molecular potency and patient attributes including muscle mass, gender, age, and ethnicity; (c) Efficacy, onset, and duration are functions of “molecular potency” defined as the number of active 150 kDa molecules available for binding; (d) “Molecular potency” is difficult to objectively quantify for commercially available toxins; (e) Up to a point, increased molecular potency decreases time to onset and increases duration of effect, and the “Molecular Potency Quotient” is a construct for comparing molecular potency commercial cost; (f) The area of effect of a toxin injection is dependent upon molecular potency, diffusion (passive), and spread (active); (g) Differing reconstitution volumes; and (h) Increased number of injection sites can affect spread, onset, and duration of effect. Conclusions The principles of BoNT‐A use in aesthetics are complex yet understandable as outlined in the framework of the updated Eight Key Clinical Postulates and serves as a useful tool for providing the most effective treatment and interpreting research on present and future toxin formulations.

Background The globally devastating effects of COVID‐19 breach not only the realm of public health, but of psychosocial interaction and communication as well, particularly with the advent of mask‐wearing. Methods A review of the literature and understanding of facial anatomy and expressions as well as the effect of botulinum toxin on emotions and nonverbal communication. Results Today, the mask has become a semi‐permanent accessory to the face, blocking our ability to express and perceive each other’s facial expressions by dividing it into a visible top half and invisible bottom half. This significantly restricts our ability to accurately interpret emotions based on facial expressions and strengthens our perceptions of negative emotions produced by frowning. The addition of botulinum toxin (BTX)–induced facial muscle paralysis to target the muscles of the top (visible) half of the face, especially the corrugator and procerus muscles, may act as a therapeutic solution by its suppression of glabellar lines and our ability to frown. The treatment of the glabella complex not only has been shown to inhibit the negative emotions of the treated individual but also can reduce the negative emotions in those who come in contact with the treated individual. Conclusions Mask‐wearing in the wake of COVID‐19 brings new challenges to our ability to communicate and perceive emotion through full facial expression, our most effective and universally shared form of communication, and BTX may offer a positive solution to decrease negative emotions and promote well‐being for both the mask‐wearer and all who come in contact with that individual.

Although oxygen is essential for proper wound healing, wounds are often hypoxic with diminished oxygen delivery to the healing tissue. Since oxygenation of the outer layers of skin is almost exclusively provided by the atmosphere, increasing the presence of external oxygen enhances the healing process. Hyperbaric oxygen therapy is beneficial for treating nonhealing wounds, such as diabetic ulcers, and has been used to speed post-treatment recovery following aesthetic procedures; however, it is not suitable for home use. Recently, perfluorocarbon emulsions have been developed that can absorb large amount of oxygen. Preparations containing 2% of these compounds can absorb up to seven-times more oxygen than water at 37dC. A topical perfluorocarbon emulsion consisting of perfluorodecalin, water, plant derived emulsifiers, and a preservative, has been developed for use in dermatology (Cutagenixt a Cutavivet Professional Skin Care Emulsion; Cutagenesis, Niwot, CO). Designed to be applied 2 to 4 times daily following skin rejuvenation procedures, this topical oxygen emulsion reduces the incidence of post-procedure complications. The application of a topical emulsion is well-suited for patient application to enhance recovery following energy-based aesthetic procedures. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4728.

Background: Despite the clinical availability and widespread usage of diagnostic and prognostic gene expression profiles (GEP) for the management of melanoma, no recommendations for Appropriate Use Criteria (AUC) exist to guide their integration into clinical practice.Objective: To develop a set of consensus-based AUC recommendations for the use of GEP profiling technology in the diagnosis and management of melanoma in specifically-defined situations commonly encountered by the practicing dermatologist.Methods: A systematic Medline literature search was performed to identify all existing evidence pertinent to the clinical efficacy and utility of three melanoma GEP tests that met the inclusion criteria (validated in peer-reviewed literature, US governmentally approved, and currently widely used) for review. A modified Delphi technique was used to achieve consensus and standard SORT criteria were applied. An expert panel of nine dermatologists/dermatologic surgeons/dermatopathologists developed a set of 29 clinical scenarios for the appropriate use of GEP assays and reviewed the available literature to make evidence-based recommendations for each indication.Results: The 2-GEP assay for melanoma diagnosis received 1 B-strength and 6 C-strength recommendations. The 23-GEP diagnostic test received 1 A-strength, 3 B-strength, and 4 C-strength recommendations. The 31-GEP prognostic assay received 1 A-strength, 7 B-strength, and 6 C-strength recommendations.Conclusions: These AUC recommendations provide an evidence-based framework for the integration of melanoma GEP tests into clinical practice.

BACKGROUND: Surgical treatment of keloid scars is associated with an approximately 70% recurrence rate at the excision site. OBJECTIVE: We sought to assess keloid recurrence rates when superficial radiation therapy (SRT) was applied following surgical excision. METHODS: Medical records were reviewed of subjects treated for keloid scars followed by SRT (SRT-100™; Sensus Healthcare, Boca Raton, Florida) using a biologically effective dose (BED) of 30Gy and for whom the required retrospective data was available. Eligible subjects (N=61) were treated for 96 keloid scars with SRT. Subjects were male (48%) and female (52%) with a mean age of 38.87 years. Subjects were treated for ≥1 keloid scars following removal by sutured excision (93%) or tangential excision with secondary intention technique (7%). Almost all subjects (98%) received BED 30Gy with irradiation scheme of three 6Gy SRT treatments on Days 1, 2 and 3 following surgery. Mean energy of 100KV (73%) or 70KV (27%) were applied. RESULTS: Ten treated keloidectomy sites (10.4%) had recurrences (i.e., presence of any new tissue growth on the surgical scar) within 12 months increasing to 11 (12.7%) at 18 months. Kaplan-Meier survival probability cure rate was 85.6% from 24 months post-SRT treatment onwards. Transient hyperpigmentation was the most frequent adverse event and there were no malignancies in the treatment area during follow-up evaluations. CONCLUSIONS: SRT with a BED value of 30 Gy delivered to keloidectomy excision sites immediately following excision was well-tolerated and resulted in markedly fewer long-term recurrences than reported following keloidectomy alone. Most keloid scar recurrences occurred within one year. There were no malignancies during follow-up evaluations.

The most common aesthetic procedure performed worldwide is the injection of botulinum neurotoxin Type A (BoNT-A). Aesthetic providers must fully comprehend the objective scientific data, theoretical mechanisms of action, and differences between brands of BoNT-A.To determine and review the relevant clinical postulates for the use of botulinum toxin in aesthetics.The BoNT-A clinical postulates presented here discuss how each brand of BoNT-A acts identically, how the molecular potency may vary between the different products, how patient age, gender, genetics, and muscle mass cause variation in toxin receptor number and density, and how both practitioner and patient can affect toxin distribution.A total of 8 clinical postulates have been identified that are key to understanding the use of botulinum toxin in aesthetics and to obtaining the best clinical results.All of these factors affect the potential efficacy of the injected toxin and hence the aesthetic results obtained.

Botulinum toxin A (BTXA) is one of the most popular nonsurgical cosmetic procedures worldwide. Overall, this procedure is associated with favorable complications profile. Nevertheless, any medical intervention carries inherent risks. This synopsis systematically reviews adverse effects of aesthetic BTXA for both approved and off-label indications. Based on published data, the approach for prevention and management is discussed.

Although oxygen is essential for proper wound healing, wounds are often hypoxic with diminished oxygen delivery to the healing tissue. Since oxygenation of the outer layers of skin is almost exclusively provided by the atmosphere, increasing the presence of external oxygen enhances the healing process. Hyperbaric oxygen therapy is beneficial for treating nonhealing wounds, such as diabetic ulcers, and has been used to speed post-treatment recovery following aesthetic procedures; however, it is not suitable for home use. Recently, perfluorocarbon emulsions have been developed that can absorb large amount of oxygen. Preparations containing 2% of these compounds can absorb up to seven-times more oxygen than water at 37deg;C. A topical perfluorocarbon emulsion consisting of perfluorodecalin, water, plant derived emulsifiers, and a preservative, has been developed for use in dermatology (Cutagenixtrade;amp; Cutavivetrade; Professional Skin Care Emulsion; Cutagenesis, Niwot, CO). Designed to be applied 2 to 4 times daily following skin rejuvenation procedures, this topical oxygen emulsion reduces the incidence of post-procedure complications. The application of a topical emulsion is well-suited for patient application to enhance recovery following energy-based aesthetic procedures. J Drugs Dermatol. 2020;19(3): doi:10.36849/JDD.2020.4728.

Background: Phototherapy is a safe and effective modality for the treatment of mild to moderate psoriasis. Objectives: To compare the efficacy and safety of the 650-microsecond, 1064-nm pulsed YAG laser with the excimer laser for the treatment of mild to moderate psoriasis vulgaris of the arms and legs. Methods: Eligible subjects (n=15) aged 54.3 ± 11.7 years enrolled in a randomized, investigator-blinded study. Psoriatic plaques on one side of the body were treated with the 650-microsecond laser and plaques on the other side were treated with the 308-nm excimer laser. Subjects made up to 15 visits, twice weekly, or fewer if full clearance was achieved. Efficacy and tolerance were evaluated by the mPASI scores and local skin reactions, respectively. Results: Both devices showed efficacy in treating psoriatic plaques. Differences between the two devices were not significant for redness, thickness, scaliness, mPASI scores for arms and legs, and overall mPASI scores for the treated psoriatic plaques on each side of the body. The investigator-assessed scores for erosion/ulceration, vesicles, erythema, scaling, edema, and atrophy were low and identical for both sides of the body. Conclusion: The efficacy and tolerance of the 650-microsecond laser is equivalent to that of the excimer laser for the treatment of mild to moderate psoriasis vulgaris of the arms and legs. J Drugs Dermatol. 2020;19(2)176-183. doi:10.36849/JDD.2020.4769

Clinical and experimental literature search has changed significantly over the past few decades, and with it, the way in which we value information. Today, our need for immediate access to relevant and specific literature, regardless of specialty, has led to a growing demand for open access to publications. The Journal Impact Factor (JIF) has been a long-time standard for representing the quality or “prestige” of a journal, but it appears to be losing its relevance. Here, we define the JIF and deconstruct its validity as a modern measure of a journal’s quality, discuss the current models of academic publication, including their advantages and shortcomings, and discuss the benefits and shortcomings of a variety of open-access models, including costs to the author. We have quantified a nonsubscribed physician’s access to full articles associated with dermatologic disease and aesthetics cited on PubMed. For some of the most common dermatology conditions, 23.1 percent of citations (ranging from 17.2% for melasma to 31.9% for malignant melanoma) were available as free full articles, and for aesthetic procedures, 18.9 percent of citations (ranging from 11.9% for laser hair removal to 27.9% for botulinum toxin) were available as free full articles. Finally, we discuss existing alternative metrics for measuring journal impact and propose the adoption of a superior publishing model, one that satisfies modern day standards of scholarly knowledge pursuit and dissemination of scholarly publications for dermatology and all of medical science.

Keloids are a fibroproliferative disorder that can result from a cutaneous injury to the reticular dermis. Recurrence rates as high as 100% have been reported following surgical excision alone. Consequently, a variety of post-surgical techniques have been employed to prevent keloid recurrence, including the use of radiation. Although numerous studies have shown post-excisional X-rays, electron beam, lasers and brachytherapy can reduce the rate of keloid recurrence, numerous inconsistencies, including a wide range of definitions for keloid recurrence, make it difficult to compare study outcomes. The review aims to examine the various means for defining keloid recurrence in clinical trials involving the use of radiation therapy. Searches of the Cochrane Library and PubMed were performed to identify the available information for post-surgical keloid recurrence following radiation therapy. Each identified study was reviewed for patient follow-up and criteria used to define keloid recurrence. The search results included clinical studies with external beam radiation, brachytherapy and superficial radiation therapy. Many studies did not include a definition of keloid recurrence, or defined recurrence only as the return of scar tissue. Other studies defined keloid recurrence based on patient self-assessment questionnaires, symptoms and scar elevation and changes in Kyoto Scar Scale, Japan Scar Workshop Scale and Vancouver Scar Scale scores. The results of this review indicate keloidectomy followed by radiation therapy provide satisfactory recurrence rates; however, clinical studies evaluating these treatments do not describe treatment outcomes or use different definitions of keloid recurrence. Consequently, recurrence rates vary widely, making comparisons across studies difficult. Keloid recurrence should be clearly defined using both objective and subjective measures.

Introduction: Acne vulgaris is a highly prevalent skin condition that can adversely affect the quality of life. Acne-predisposed skin is in a state of subclinical inflammation leading to skin barrier dysfunction. A multi-center cohort study was designed to evaluate clinical efficacy and safety of twice daily facial cleansing using an oscillatory sonic brush, acne brush head, and cleansing gel for 4 weeks. Methods: Subjects with mild-to-moderate acne and acne-prone skin used the cleansing regime after which they applied the skin care products they routinely used. Physician-assessed skin condition comparing baseline versus week 4 using the FDA/IGA scale and subject satisfaction with cleansing efficacy and handling properties of the regime were scored during the last visit. Results: Forty-six subjects completed the study. Physician-scored skin condition showed a statistically significant improvement in FDA/IGA scores and a significant reduction of inflammatory and non-inflammatory lesions comparing baseline versus 4 weeks. Thirty-five (76.0%) subjects had cleared or almost cleared. Subjects similarly assessed their skin to be improved. Conclusion: Both the physician and subject scores revealed the gentle cleansing routine using the sonic brush to be effective reducing the number of acne lesions, improving skin condition. No adverse events were reported during the study period. The cleansing regime may offer an attractive, safe option for maintenance and treatment of subjects with mild-to-moderate acne and acne-prone skin. J Drugs Dermatol. 2019;18(11):1140-1145.

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A new temperature-controlled device has been used as a percutaneous radio frequency probe to treat lax submental and other facial areas. It has significant advantages over other esthetic devices as it provides the dual benefit of fat lipolysis and skin tightening. Our goal here is to present consensus recommendations for treating the aging neck.A panel of 11 expert physicians convened in Dallas, Texas, on October 15, 2016 to arrive at a consensus on the best current practice for submental skin tightening and contour improvement. Prior to the meeting, a comprehensive review of the literature was performed and a survey was sent to esthetic dermatologists and plastic surgeons who were queried about various aspects of neck rejuvenation.The literature search revealed 10 different technologies for neck rejuvenation evaluated in double-blind (n = 2) and single-blind (n = 1) clinical trials and other clinical evaluations (n = 21). The survey was sent via an email to 1248 individuals and was completed by 92 respondents. Review of the data and discussion by meeting attendees generated eight consensus recommendations.Subdermal monopolar radio frequency represents an effective means for disrupting fat volume and skin tightening of the face, neck, and jawline. For suitable patients, this treatment can be used to achieve significant esthetic improvements.

Objective: Photodynamic therapy (PDT) using 10% 5-aminolevulinic acid (ALA) gel (GEL) has been shown to be highly effective for treating actinic keratosis (AK) but has only been studied using red-light activation. The goal of this study was to compare GEL and a 20% ALA solution (SOL) using blue-light activation under typical clinical conditions. Design: This double-blind, split-face study randomized subjects to GEL or SOL application to contiguous 25cm(2) fields containing 4 to 8 AK lesions on either side of the face or scalp (no curettage, 1-hour incubation, no occlusion) followed by blue light exposure (1,000 seconds, 417nm, 10J/cm(2)). Participants: Forty adult subjects were treated on either the face (n=20) or scalp (n=20). Measurements: Primary outcomes included change in baseline AK lesions. Secondary outcomes included local skin reaction (LSR) scores and visual analog scale (VAS) pain scores. Results: Lesions treated with GEL were 97.1 percent cleared at Day 84 versus 94.9 percent for lesions treated with SOL (p

Objective: We sought to provide short- and long-term data on the duration of results and patient satisfaction achievable with absorbable suspension sutures in the midface. Design: This study included a prospective, masked, controlled 12-week study and 12-month extension study. Setting: This study was conducted in a single center in Aventura, Florida. Participants: Twenty female subjects 41 to 75 years of age with moderate facial skin laxity were included. Measurements: Facial lift was measured using a three-dimensional surface imaging system. Global Aesthetic Improvement Scale (GAIS) scores were reported by subjects and investigators and FACE-Q questionnaires were collected from subjects at Weeks 1, 2, 8, and 12 and Month 12 after treatment. Results: Statistically significant changes in lift were observed through Week 8 (30% of patients had ≥1.5mm of lift [p=0.03]) and mean surface area of lift through Week 12 (patients with ≥1.0mm facial lift had mean surface area of 4.4cm(2) [p=0.156]). Improvements in subject and investigator GAIS were observed, along with statistically significant changes in FACE-Q assessments and patient-reported apparent age at each timepoint through 12 months. Subjects tolerated the procedure well, and adverse events were minimal. Conclusion: Absorbable suspension sutures offer an adaptable, safe, minimally invasive approach to tissue lifting and repositioning. The suture provides immediate lift, followed by revolumization and ongoing recontouring that result from the collagen-stimulating properties of the suture, increasing long-term patient satisfaction.

Scars are an unavoidable consequence of cutaneous surgery. Healing with an excellent cosmetic outcome is a crucial component to any surgical wound to avoid any negative impact on quality of life. Various products exist which claim to improve post-surgical scar appearance and texture. In this blinded, randomized pilot study, we compared the efficacy of a silicone-based topical gel containing Pracaxi oil (PO Gel; Serica™ Moisturizing Scar Formula; Cynova Laboratories, Houston, TX) against a second silicone-based gel containing Cepalin onion extract (OE Gel; Mederma® Advanced Scar Gel, Merz, North America). The Vancouver Scar Scale (VSS), Physician and Subject Global Assessment of Scar Treatment, and digital photography were used to determine efficacy and superior post-surgical care treatment outcomes. Forty healthy subjects (18-75 years old) with recent surgical scar (1 to 4 months old) were randomized to PO gel or OE gel and asked to apply a topical solution three times daily for 8 weeks. There were six study visits (Baseline and Weeks 2, 4, 8, 12 and 16). The results of this study showed that subjects with post-surgical scars achieved significant improvements at 8 and 12 weeks following application of a product with either Pracaxi oil or onion extract gel, based on mean Vancouver Scar Scale scores. Both products generally improved the individual scar signs and symptoms. Subjects using the onion extract product did not achieve improvement in Pain or Itch at the 8-week evaluation or Pain at the 12-week evaluation.

Treatment options for acne vulgaris are enhanced by laser and light therapy. Both visible and laser light are effective treatments for acne. Visible light and many lasers target Propionibacterium acnes porphyrins while others act as anti-inflammatory mediators or reduce sebaceous gland activity. Compared with topical and systemic therapies, laser and light therapies have few if any side effects and appear to be safe during pregnancy. If patients prefer at home light treatments, several devices are currently available and have been shown to have efficacy. Ultimately, combining laser and light with topical therapy may well become the mainstay of acne treatment.

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.

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Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

pBACKGROUND: Signs of facial aging include wrinkles, loss of subcutaneous volume, decreased tone, texture, and sagging of the skin. The objective of this review is to determine whether facial suspension absorbable sutures are a safe and effective modality for facial rejuvenation./ppMETHOD: A group of US plastic surgeons and dermatologists who practice medical aesthetics convened to review evidence obtained from literature searches and to reach a consensus on clinical practice guidelines for the use of facial absorbable suspension sutures./ppRESULTS: Currently, there are different types of lifting sutures available. Absorbable, facial suspension sutures allow for superior repositioning of tissue along a vector line together with the added benefit of volumization of the area. These benefits are for patients who have moderate facial aging and require treatment beyond the use of injectable products only./ppCONCLUSIONS: Treatment with absorbable facial suspension sutures, when performed properly, is associated with minor and infrequent complications and offers a beneficial clinical alternative to traditional facial rejuvenation techniques./ppemJ Drugs Dermatol. 2017;16(7):661-666./em/p.

Summary The treatment of acne, especially severe acne, remains a challenge to dermatologists. Therapies include retinoids, antibiotics, hormones, lights, lasers, and various combinations of these modalities. Acne is currently considered a chronic rather than an adolescent condition. The appropriate treatment depends on the patient and the severity of disease. The purpose of this study was to review current therapies for acne of all severities and to introduce the 650-μs 1064-nm laser for the treatment of acne.

Time to onset of response and duration of response are key measures of botulinum toxin efficacy that have a considerable influence on patient satisfaction with aesthetic treatment. However, there is no overall accepted definition of efficacy for aesthetic uses of botulinumtoxinA (BoNT-A). Mechanical methods of assessment do not lend themselves to clinical practice and clinicians rely instead on assessment scales such as the Frontalis Activity Measurement Standard, Frontalis Rating Scale, Wrinkle Severity Scale, and Subject Global Assessment Scale, but not all of these have been fully validated. Onset of activity is typically seen within 5 days of injection, but has also been recorded within 12 hours with abobotulinumtoxinA. Duration of effect is more variable, and is influenced by parameters such as muscle mass (including the effects of age and sex) and type of product used. Even when larger muscles are treated with higher doses of BoNT-A, the duration of effect is still shorter than that for smaller muscles. Muscle injection technique, including dilution of the toxin, the volume of solution injected, and the positioning of the injections, can also have an important influence on onset and duration of activity. Comparison of the efficacy of different forms of BoNT-A must be made with the full understanding that the dosing units are not equivalent. Range of equivalence studies for abobotulinumtoxinA (Azzalure; Ipsen Limited, Slough UK/Galderma, Lausanne CH/Dysport, Ipsen Biopharm Limited, Wrexham UK/Galderma LP, Fort Worth, TX) and onabotulinumtoxinA (Botox; Allergan, Parsippany, NJ) have been conducted, and results indicate that the number of units of abobotulinumtoxinA needs to be approximately twice as high as that of onabotulinumtoxinA to achieve the same effect. An appreciation of the potential influence of all of the parameters that influence onset and duration of activity of BoNT-A, along with a thorough understanding of the anatomy of the face and potency of doses, are essential to tailoring treatment to individual patient needs and expectations.

Non-thermal laser therapy in dermatology, is a growing field in medical technology by which therapeutic effects are achieved by exposing tissues to specific wavelengths of light.The purpose of this review was to gain a better understanding of the science behind non-thermal laser and the evidence supporting its use in dermatology.A group of dermatologists and surgeons recently convened to review the evidence supporting the use of non-thermal laser for body sculpting, improving the appearance of cellulite, and treating onychomycosis.The use of non-thermal laser for body sculpting is supported by three randomized, double-blind, sham-controlled studies (N = 161), one prospective open-label study (N = 54), and two retrospective studies (N = 775). Non-thermal laser application for improving the appearance of cellulite is supported by one randomized, double-blind, sham-controlled study (N = 38). The use of non-thermal laser for the treatment of onychomycosis is supported by an analysis of three non-randomized, open-label studies demonstrating clinical improvement of nails (N = 292).Non-thermal laser is steadily moving into mainstream medical practice, such as dermatology. Although present studies have demonstrated the safety and efficacy of non-thermal laser for body sculpting, cellulite reduction and onychomycosis treatment, studies demonstrating the efficacy of non-thermal laser as a stand-alone procedure are still inadequate.

pDermatologists treat actinic keratosis (AK) primarily because these lesions have the potential to progress to invasive squamous cell carcinoma. Patients, on the other hand, generally seek treatment to remove the lesions and achieve an improved appearance of their skin following treatment. In selecting a treatment option for AK, dermatologists should consider post-treatment cosmesis, because cosmetic outcomes differ across AK treatments. To obtain expert opinion on the cosmetic sequelae related to chronically photodamaged skin and the treatment of AK, an expert panel meeting among dermatologists was conducted in February 2016. These experts reviewed current treatment options for photodamage, including AK, and discussed the relative merits of the various cosmetic assessments commonly used by investigators and patients in both clinical trial and dermatology practice settings. A main goal of the expert panel meeting was to propose assessment tools that could be specifically designed to characterize cosmesis results after treatment of AK. The panel agreed that existing tools for measurement of cosmetic outcomes following treatment of photodamage could also be used to evaluate cosmesis after treatment of AK. Digital photography is probably the best method used for this, with validation by other technologies. Better measurement tools specifically for assessing cosmesis after AK treatment are needed. Once they are developed and validated, regulatory agencies should be educated about the importance of including cosmetic outcomes as a component of product labeling./ppemJ Drugs Dermatol. 2017;16(3):260-265./em/p.

Ever since the first published report of the application of botulinum toxin for cosmetic use by Carruthers et al. in 1990, the practice quickly expanded, taking only a few years to gain widespread acceptance and adoption. There now exist numerous different drug preparations, using one of multiple different toxins, with more popular trade names including Botox, Dysport, and Xeomin, to name a few. A number of different applications for these neurotoxins have also expanded in the past few decades. This chapter aims to provide a brief overview of the indications, possible complications, and essential steps involved in cosmetic neurotoxin injection. It also provides an example of the operative dictation.

OnabotulinumtoxinA was introduced to the US market in 2002 as the first botulinum toxin type A (BoNTA) approved for facial aesthetics. This article provides an overview of onabotulinumtoxinA's uses and indications as well as safety and efficacy data. As with other BoNTA products, onabotulinumtoxinA is generally well tolerated. Consideration is also given to clinical applications of the product. Information on handling, storage, and dosing is provided.

IncobotulinumtoxinA is the third botulinum neurotoxin type A (BoNTA) to be approved for aesthetic use in the United States. This article introduces the new product with an overview of clinical applications and a discussion of the neurotoxin's molecular structure. The role and clinical relevance of complexing proteins in BoNTA products are discussed. Finally, incobotulinumtoxinA's mechanism of action is described.

IncobotulinumtoxinA is the third neurotoxin type A to be approved for aesthetic use in the United States. Because incobotulinumtoxinA has been in use in Europe for some time, the clinical literature is fairly replete with references to its properties and characteristics, as well as its safety and efficacy. In North America, 2 pivotal trials, referred to as GL-1 and GL-2, investigated the safety and efficacy of incobotulinumtoxinA in the glabellar region; both are currently in press with another journal. Other published studies of incobotulinumtoxinA are also described in depth in this article, including reports on aesthetic indications, diffusion, therapeutic indications, and studies pertaining to the preclinical and clinical pharmacology of incobotulinumtoxinA. Topics addressed include potency variability, mean concentration, stability and dissociation, and endopeptide immunoassay.