Cosmetic Dermatology Dr. Shehnaz Arsiwala MD, DDV Consultant Dermatologist Prince Aly Khan Hospital, Saifee Hospital, Mumbai IndiaId : Digital Lecture Series : Chapter 26 CONTENTS Introduction Cosmetics Topical therapies Moisturizers Sunscreens Antiaging cosmeceuticals Cosmetic camouflage Adverse reactions Procedures Chemical Peels Microdermabrasion Fillers Botulinum toxin Platelet rich plasma Lasers MCQs Photo Quiz Introduction Cosmetic dermatology is a rapidly developing field of medicine. Various therapies and procedures are used to enhance ones aesthetic looks and appearance. Common cosmetic problems include acne, pigmentation, age- related, hair and nail problems. Various topical therapies and interventional procedures are used to address these cosmetic problems. Cosmetics and Cosmeceuticals Cosmetic : Any article intended to be rubbed, poured, sprinkled, or sprayed on, introduced into, or otherwise applied to the human body for cleansing, beautifying, or altering the appearance. Commonly used cosmetics : Soaps, shampoos, moisturizers, anti- aging products, eye and lip cosmetics, bleaching and hair products. Cosmeceutical agents : Pharmacological agents which have an effect intermediate between cosmetics and drugs. Cosmeceutical botanicals, retinoids, skin lightening agents, sunscreens. Adverse reactions to cosmetics and cosmeceuticals can occur. Moisturizers Moisturizers are agents which hydrate the stratum corneum by either providing water or helping to draw water from the deeper layers of the skin. Oil-in water or water in oil preparations. Sunscreens, anti-ageing products like retinols, alpha or beta hydroxy acids and skin-lightening agents may be added to moisturizers. Moisturizers - types Oil-in-water : More cosmetically acceptable by patients Not very effective for very dry skin conditions Cream or lotion formulations Water-in-oil : Create an occlusive film on the skin surface; reduce water loss and traps moisture in the skin Stickier, less cosmetically acceptable More effective for dry skin and ichthyotic conditions Moisturizers cosmeceutical agents Contents of moisturizers : Stearic, linoleic, linolenic, oleic, and lauric acid, fish oil, petrolatum, shea butter, and sunflower seed oil Petroleum jelly, lanolin, mineral oil, and silicones. Glycerol, pyrrolidine carboxylic acid, Urea, lactic acid, glycolic acid. Sesame oil, wheat germ oil and Vit E. Bisabolol, squalane. Sun and Ultraviolet index Ultraviolet index : Informs about amount of harmful effects of UVL on earth on a particular day. minimal-sunburn occurs over an hour low-sunburn in mins moderate-sunburn in mins high-sunburn in mins v high-sunburn in30. Method of sunscreen use Select a sunscreen SPF with UVA and UVB protection. Apply mins before exposure. Reapply generously after swimming or sweating. Select water resistant one for beach/outdoor activity associated with perspiration. To avoid eye stinging, avoid sport gel formula and avoid benzophenones. To maximize eye protection appropriate sunglasses, polarizing lenses. Lipsticks sunscreens-useful. Antiaging cosmeceuticals Cosmetics formulations with pharmaceutical actions. Cosmetics with drug like advantages and have ingredients that influence biologic function of skin. Products are formulated with ingredients of pharmaceutical strength. Topical antioxidants, cosmeceutical botanicals and retinoids are important ingredients. Topical retinoids Tretinoin, adapalene, tazarotene, isotretinoin. Retinaldehyde and retinol esters. Used in : Acne Photoaging Pigmentation Adverse effects : Retinoid dermatitis : redness, burning, dryness Post inflammatory pigmentation Acne flare up Classification of Antioxidants Fat Soluble AntioxidantsPolypodium Leucotomos Vitamin EResveratrol CarotenoidsGrape Seed Extract CoQ10/IdebenonePomegranates LycopeneFat And Water Soluble Antioxidants Water Soluble AntioxidantsAlpha Lipoic Acid GlutathioneMiscellaneous Vit CGenistein Green Tea- PolyphenolsPycnogenol SilymarinDehydroepiandrosterone Coffeberry ExtractSelenium Carotenoids Vitamin A derivatives Exfoliation, keratin regulation, epidermopoesis, collagen remodelling and angiogenesis, anti-acne actions. Improves photodamage, pigmentation, texture, fine lines and wrinkles. Retinoid dermatitis, sun sensitivity and irritation are common problems. Short contact, night use and low strength is recommended while starting. Oral carotenoids are used for photoprotection and anticancer actions. Topical Vitamin E and Vitamin C Vitamin E Photoprotection, reduces photoaging. Improves skin roughness and reduces wrinkling. Anti-inflammatory and immunostimulatory. Wound healing, emollient properties. Vitamin C Water-or lipid-soluble forms. Photoprotective and anti-inflammatory. Reduces photoaging and wrinkles. For effective topical application, vitamin C must be non-esterified, acidic and optimally at 20% concentration. Green tea-polyphenols Green tea belongs to polyphenolic catechin group. Green tea is one of the most studied antioxidants. GTPs include extracts such as epicatechin, epigallocatechin, epicatechin-3-gallate, and epigallocatechin 3-gallate (EGCG); the anticarcinogenic effects of green tea are attributed to these extracts and particularly to EGCG. EGCG is the main and most potent antioxidant compound in green and white tea. The polyphenols in green tea are excellent antioxidants, anti- inflammatory and anticarcinogenic agents. They prevent UV-induced oxidative damage and induction of matrix metalloproteinases. Idebenone A synthetic analogue of coq10. Reduces the photodamage and also reduces fine wrinkles, roughness and dryness in the aged skin. Contact dermatitis is the most popular side effect noted. Alpha lipoic acid (ALA) Fat and water soluble Antioxidants. Organosulfur compound obtained from octanoic acid. It is an important network antioxidant and an essential cofactor in mitochondrial dehydrogenases. Antioxidant effects are due to bioactive form of LA which is strong anti inflammatory agent. Useful for preventing UVB induced erythema, photodamage and cancer. Supplement used primarily as a "weight loss" and "energy" supplement. Cutaneous benefits of ALA Include accelerated chronic wound healing. Antioxidants : Clinical perspectives The clinical use of antioxidants is increasing. The use for these cosmeceuticals is either as single agent or in combinations Correction - fine lines, pigmentation, texture. Prevention - Maintenance of correction obtained and true prevention. Added in formulations for photoprotection. Antiinflammatory, lightening, immunoprotection and anticancer actions antimicrobial, and wound healing properties. Orally or topically used. Fine lines, texture and photodamage improvement after 12 weeks of antioxidant cosmeceuticals Cosmetic camouflage Concealing of unsightly marks on the skin with specially matched opaque creams and powders. Contents : Calamine, zinc oxide, bentonite Colour pigments Setting powder Indications : Vitiligo Freckles Melasma, post inflammatory pigmentation Hemangiomas, Nevi Scars Adverse reactions to cosmetics and cosmeceuticals Soaps : Repeated use may strip the skin of its protective lipid layer. Shampoos : Daily washing with harsh shampoos can dry the shaft and make it brittle. Fragrances : May cause photocontact dermatitis. Hair colors : Frequent hair lightening or coloring can cause irreversible damage to the hair shaft. Cosmetic alopecia may follow. Adverse reactions to cosmetics and cosmeceuticals Moisturizers : Comedogenic ingredients like isopropyl myristate irritate the pilosebaceous follicles. Sunscreens : Vehicle may exacerbate or induce acne; contact folliculitis may occur. Skin lightening agents : Excessive and prolonged use may cause exogenous ochronosis. Interventional procedures Chemical Peels Microdermabrasion Microneedling Injectables - botulinum, fillers, PRP Lasers and other technologies Chemical Peels Mechanism Epidermal and part of dermal tissue replacement by Destruction Elimination Regeneration and remodelling Controlled stage of inflammation Classification of Peeling : Depth of Injury Superficial Wounding (Light peel) Stratum granulosum, papillary dermis Medium Depth Wounding (Medium peel) Upper reticular dermis Deep Depth Wounding (Deep peel) Mid reticular dermis Depth of peels Depth of peel is dependent upon Chemical applied Concentration of chemical Skin type Preparation of skin Technique of application Superficial and mild medium depth peels most popular, moderate medium depth and deep peels are now replaced by laser resurfacing techniques. Peel Chemicals Alpha hydroxy acids (AHAs) : Glycolic, lactic, mandelic, pyruvic Beta hydroxy acids : Salicylic acid Trichlorocetic acid, phenol Combinations - AHA cocktails - phytic peel Newer peels - retinol, arginine peel, azelaic acid peel, acetic acid, phytic, etc. Indications Pigmentary conditions - Melasma, photodamage, post inflammatory hyperpigmentation, freckles, lentigenes. Early Acne scars with residual active acne, Truncal acne. Acne scars without active acne; with/without pigmentary changes. Improving fine lines - early wrinkles. Improving texture and glow. Contraindications Unrealistic expectations Keloid tendency Active severe acne Active herpes simplex or bacterial infections. Isotretinoin recipient in last 6 months. Unstable vitilligo and psoriasis. Associated photo aggravated skin diseases. Salicylic peels during pregnancy, lactation and those sensitivity to aspirin. Phenol peels in cardiac patients. Pre-treatmentAfter 35% glycolic acid peels, 4 sessions Chemical peels for acne scars Glycolic acid peels along with topical treatments in Melasma Complications CommonLess common Erythema Hyperpigmentation Irritation Dryness Persistent Erythema Hypopigmentation Contact Dermatitis Bacterial Infections Reactivation Of Herpes Acneiform Eruptions Milia Photosensitivity Hypertrophy/Keloids Microdermabrasion Causes resurfacing by mechanical micro-abrasion of skin and is a non- invasive office procedure. Aluminium crystals or abraded diamond tips can be used works on vaccuum suction principle. Indications : Improves mild acne scars Improves skin texture, fine lines Minimizes superficial pigmentation Improves fine lines Striae Can improve open pore appearance Microneedling Non invasive procedure with an instrument dermaroller. Creates micro injuries to the epidermis resulting in skin regeneration and collagen induction. The micro needled tissue repairs by collagen stimulation and hence it is also called as collagen induction therapy. Indications : Acne scars, post surgical or traumatic scars Wrinkle correction Trans-epidermal drug delivery Stretch marks Microneedling The procedure involves a series of sessions performed after applying an anesthetic cream. The dermaroller is rolled into the skin over a few minutes. The post treatment skin appears slightly red and has minimal downtime as patient can get back to work on same day. Absolute sun protection before the procedure and in the interim phase is recommended. The results are visible depending on the type of problem that is to be corrected textural improvement is seen after first sitting and scar improvement is visible after a series of sessions. Pre TreatmentPost Treatment Microneedling Injectables Fillers Botulinum toxin Platelet rich plasma therapy Various therapeutic modalities in cosmetic dermatology, especially the injectables, laser and technology based devices are used to improve the appearance of ageing in the skin which may be due to chronological or extrinsic effects. Ageing Intrinsic or Chronological Genetic makeup Extrinsic factors Solar effects Smoking, Alcohol Malnutrition Gravitational effect Sleep lines Muscular action Mechanisms of skin ageing With chronological ageing, skin begins to lose firmness and lift - causes the skin to look older. At molecular level, the connective tissue in the skin becomes weaker, the body produces less collagen and elastin, the key components of healthy, youthful looking skin. In women the breakdown of collagen and elastin is enhanced by exposure to external factors. Sagging in the aging face occurs due to gravity and changes in the fat compartments. The loss of fat pads in the upper and mid face and around the mouth, tightening of the central ligaments and loosening of the lateral ligaments- results in the arc of aging of the older faces. Age related skin changes Epidermis Thinner, Flattening of DE junction Slow multiplication of cells and delayed healing time Dermis Loss of dermal thickness Disorganized collagen bundles, abnormal elastin Changes in glycosaminoglycans less water holding power Changes in appearance Dryness, Skin peeling Roughness, Pallor Loss of protective power, delay in recovery from surface damage Delaying skin ageing - Tips Avoid Sun Exposure - Exposure to UV light will increase the potential for fine line and wrinkle formation. Stop Smoking - Smoking depletes the skin of critical moisture and predisposes you to wrinkle formation. Get Plenty of Rest - Sleep provides a way for your body to relax and rejuvenate. Maintain hydration of skin. Use a Humidifier - Humidifiers provide moisture to the air preventing the skin from dehydrating. Night use of retinol or hyaluronic acid or oligopeptide creams. Antioxidants will also help to protect the skin throughout the day when applied in the morning.' Fillers Using dermal fillers is a treatment of wrinkles, folds or loss of facial volume through a minimally invasive technique. Fillers are most popular and easy to perform. Best option for deep folds and grooves in antiaging concepts so far. Important to choose a right technique for different face areas. Always fills % of deep wrinkles. Dermal fillers Types of fillers : Temporary : gets absorbed in 3 to 6 months Semi-permanent : absorbed within 2 years Permanent : lasts longer than 2 years Sources : Heterograft/Xenograft : Bovine collagen, porcine collagen, hyaluronic acid Allografts : Human-derived collagen Autografts : Autologous fat, collagen,fibroblasts Synthetic : Silicone, polytetrafluoroethylene Classification of Dermal Fillers Replacement Fillers : Restore soft tissue volume lost in deep dermis or subcutaneous space. Collagen. Hyaluronic acids (HAs). Stimulatory Fillers : Restore volume by stimulating fibroblast activity, collagen synthesis and soft tissue growth. Poly-L-lactic acid (PLLA). Polymethylmethacrylate (PMMA) - Permanent. Calcium hydroxylapatite (CaHA). Target zones that are commonly treated Nasolabial folds smile lines Lip rhytides upper lip lines Marionette lines lines around mouth Volume enhancement sunken cheeks Lip filling and contouring Chin and cheek augmentation Tear trough treatment under eye Back of hands Neck and chest How are they placed under the skin : Injection techniques Hyaluronic acid Commonly used filler. Naturally occurring linear polysaccharide found in extra cellular matrix of connective tissue and serves as a ground substance. Exhibits no species or tissue specificity. It is cross-linked for stability in tissues. Are superior to collagen fillers with minimal allergy and immunogenicity reports. Fillers : Nasolabial fold correction After linear threading nasolabial folds Botulinum toxin (BTX) BTX is natural, purified protein relaxes wrinkle-causing muscles creates a rejuvenated and more youthful appearance. Produced by the bacterium clostridium botulinum (Serotype A). Inhibits release of acetylcholine at the neuromuscular junction causing temporary flaccid paralysis of muscle. Resultant effects of BTX BTX effect takes 2-3 days, full effect seen 7-15 days post treatment. The effect lasts 4-6 months or longer, patient dependent. May last longer with repeated treatments. Result will wear off progressively (not sudden). Recommendations for Reconstitution and Handling Diluent0.9% non-preserved sterile saline Concentrationratio of 100 U/ 2.5cc Storage Before reconstitution After reconstitution 2C to 8C for up to 24 mo Up to 6 wks at 4C HandlingSpecial precautions not required Cosmetic indications of BTX Frown lines BETWEEN THE EYEBROWS Crows feet on outer part of eyes. Forehead lines horizontal lines on forehead seen when eyebrows are raised. Bunny lines or nasal scrunch are seen at sides of nose while scrunching the nose. Marionette lines Where the muscles pulling the corners of the mouth down are stronger than those pulling it up. Popply chin this results from the contraction of the mentalis muscle. Platysmal bands are vertical neck bands that appear with age. Facial sculpting Square to lean jaw is to relax the hypertrophic masseters muscles which give most of the asian patients a square jaw look. Global correction upper half of face Platelet rich plasma therapy (PRP) A tool of the modern era of regenerative processes. Preparation of an autologous platelet concentrate suspended in plasma, also known as platelet-rich plasma, contains growth factors and it is administered to wound sites for wound healing, tissue repair. Growth factors released from activated platelets initiate and modulate wound healing in both soft and hard tissues. Indications Hair growth Antiaging Rejuvenation Scar healing Technique The injections are performed using very small needles after numbing the skin with a surface anesthetic cream over one hour. A recovery period involving transient swelling; and in some cases, bruising which is mild and transient. PRP evokes an inflammatory response which is desired. The results are normally seen within 2-3 months and may require 3 to 5 separate sessions. In general, usually over a 3 to 4 week interval, patients should be able to see improvements in: skin texture; complexion; and tone. These improvements can continue for up to a year. LASER L- Light A- Amplification by S- Stimulated E- Emission of R- Radiation. Principle : Chromophore Action of lasers is through the chromophores. Chromophores absorb energy and are destroyed. Oxyhemoglobin, hemoglobin, melanin and water are the main skin chromophores. Lasers may lead to damage of the collateral structures - PHOTOTHERMOLYSIS. Principle : Selective photothermolysis Only wavelengths of light absorbed by the target tissue than the surrounding tissue are selected. Light is delivered in pulses to prevent diffusion and thermal damage to surrounding tissue. Energy is delivered to target in less time than required for heat diffusion to surrounding tissue. Thermal Relaxation Time Time taken by the chromophore to loose 63% of its heat after being heated up. Different chromophores have different thermal relaxation times depending upon their size. TRT predicts the PULSE WIDTH to be used for a particular chromophore. TargetSizeTRT Tatoo ink particle110 ns Melanosome11 us Erythrocyte720 us Epidermis501 ms Blood vessel501 ms Ectatic bold vessel10015 ms Hair Follicle ms Wavelength x-rays cosmic rays Microwaves TV and radio waves Excimer Argon KTP Dye Ruby Alexandrite Nd:YAG Er:YAG CO UV VISIBLE INFRARED 400 nm 700 nm Holmium 2100 Lasers Lasers for hair reduction Pigmentary lasers Resurfacing lasers Vascular lasers Other technology based devices include use of radiofrequency and high frequency ultrasound- used in skin tightening and body contouring. Lasers for Hair Removal Long pulse Ruby laser694 nm. Long pulse Alexandrite laser755 nm. Long pulse Diode laser800 nm. Long pulse Nd : YAG laser1064 nm. Intense pulsed light400 1200 nm. Diode- 28J/cm2, 100ms. 3sessions Pre TreatmentPost Treatment Lasers for Pigmented Lesions Q- switched lasers Frequency doubled Nd : YAG laser532 nm. Ruby laser694 nm. Alexandrite laser755 nm. Nd : YAG laser1064 nm. 1064 Q Switched ND YAG Laser for Tattoo Removal Pre treatment Immediate Post treatment Post treatment After 2 sessions Ablative Lasers NON ABLATIVE LASERS and Radiofrequency Erbium YAG laser 2940 nm. CO 2 laser nm. Indications Acne scars Wrinkles Rhinophyma, xanthelesma Verrucous epidermal nevi Infrared lasers 1320 nm Nd : YAG laser 1450 nm Diode laser 1540 nm Erbium Glass laser Broad band light Intense pulsed light Non ablative radio frequency Indications Wrinkles Superficial atrophic scars Laser resurfacing - Grade 2 rolling & superficial boxcar scars Post Treatment Pre Treatment Combination Therapy with Q switched ND YAG laser and fractional carbon dioxide laser : Texture, pigmentation and acne scars improvement Lasers for Vascular Lesions Flash pumped pulse dye laser585 nm. Long pulse Alexandrite laser755 nm. Long pulse FD Nd : YAG laser532 nm. Intense pulsed light nm. Long pulse Nd : yag Laser1064 nm. Excimer Laser Monochromatic light of wavelength 308 nm Targeted treatment of : Vitiligo Psoriasis Complications of Laser Persistent erythema Vesiculation and crusting Hyperpigmentation Hypopigmentation Scarring Good expertise minimal complications Q.1) Ultraviolet index A.Informs about amount of harmful UVL on earth on a particular day B.Informs about SPF factor C.Informs about sunburn factor D.Informs about UV damage Q.2) Chemical peels destroy A.Epidermis B.Dermis C.Oil glands D.Epidermis and part of dermis MCQs Q.3) This is not a chromophore for lasers A.Water B.Gas C.Oxyhemoglobin D.Melanin Q.4) Thermal Relaxation Time predicts A.The pulse width to be used for a particular chromophore B.The fluence used C.The spot size D.Thermal damage time MCQs Q.5) Wavelength of diode laser for hair removal is A.810nm B.1064nm C.655nm D.786nm Q.6) Botulinum toxin A.Inhibits release of acetylcholine at the neuromuscular junction B.destroys nerve axons C.causes myelin sheath denervation D.causes activation of neuromuscular junction MCQs Q. What laser can be used to clear this tattoo? Photo Quiz Q. What interventions can be considered for this patient with acne scars, aging skin and melasma? Photo Quiz Thank You!