Dr. Ross began his talk with an educational journey through the history of lasers. He notes that pulsed dye laser (PDL) was the first laser that was really designed for its job. In the 1990s, two major procedures changed the way that cosmetic laser dermatology was delivered: laser hair reduction, and full face and chest/neck IPL treatments.
In present day, cosmetic laser therapy emphasizes 3-dimensional restoration of the skin using a layered approach. The three main focuses for rejuvenation are surface color, texture and tone, and contour of the skin.
For facial rejuvenation (eg. wrinkles) and acne scars, non-ablative fractional and ablative fractional lasers are the most effective options. KTP, followed by PDL and IPL, are the best options for vascular lesions. Alexandrite, 810 nm diode, 980 nm diode, and Nd YAG may also be considered. The most commonly used lasers for tattoo removal are Q-switched 532 nm, ruby, alexandrite, and 1064 nm. Q-switched 532 nm, ruby, and alexandrite are also the best lasers for epidermal pigmented lesions, although post-inflammatory hyperpigmentation is a concern.
Conditions that are more difficult to treat include melasma, diffuse warts, flushing, vascular lesion in patients with darker skin, skin tightening, acne, some leg veins, and rejuvenation of the neck. While some lasers have been reported to be effective, these conditions represent an ongoing challenge and opportunity for future growth and innovation in lasers.
Skin Tightening with Creams, Hormones, Laser Resurfacing, and Surgical Lifting Ronald Moy, MD, FAAD
Dr. Moy led us through an illuminating discussion on various modalities for skin tightening. First, he discussed that hormone decline is at the root of many aging-related diseases, and hormone replacement therapy (HRT) is a cornerstone of anti-aging therapy. Estrogen replacement has been shown to increase skin thickness, epidermal hydration and skin elasticity, reduce wrinkles, and enhance vascularization and both content and quality of collagen. Of note, estrogen is safe to use in women with a history of breast cancer, and bioidentical estrogen is superior to synthetic estrogen. Topical application of estrogen cream can similarly increase skin thickness and improve appearance of wrinkles. Hormone replacement therapy with testosterone was also shown to significantly increase collagen content in postmenopausal women. Both oral DHEA replacement (50mg) and topical DHEA can provide anti-aging effects through increased skin thickness, sebum production, collagen metabolism, and epidermal hydration. Human growth hormone replacement has multiple benefits, including preventing skin thinning and sagging, as well as an overall improved feeling of well-being and prevention of Alzheimers, osteoporosis, and heart disease. Topical epidermal growth factor cream has been shown to thicken skin, decrease senile purpura, and improve wrinkles and signs of photoaging. Clinical applications for topical GF cream are to improve the appearance of under-eye bags, atrophic acne scars, and senile purpura.
Laser resurfacing may also help to tighten skin. This is a minimally invasive alternative to surgical treatments such as blepharoplasty and face- or neck-lifts. Fractional carbon dioxide laser resurfacing as well as radiofrequency treatment provide significant improvement in skin tightening of upper eyelids, infraorbital skin, cheeks, jowls, neck, and peri-ocular rhytids. Immediate skin tightening can be seen; heating of the skin is thought to promote immediate contraction of collagen, immediate collagen remodeling and elasticity, and long-term stimulation in producing new collagen. Under the skin radiofrequency is also available through technologies such as AccuTite and FaceTite.
Poster of the Day
Safety and Efficacy of Once-Daily Roflumilast Cream 0.3%, a Potent Phosphodiesterase-4 Inhibitor, for the Treatment of Psoriasis in the DERMIS-1 and DERMIS-2 Phase 3 Trials
Roflumilast is a selective and highly potent phosphodiesterase-4 inhibitor under investigation as a once-daily, nonsteroidal topical treatment for psoriasis. This poster presented the safety and efficacy results from the DERMIS-1 and DERMIS-2 trials, two identical phase 3, randomized, double-blind, vehicle-controlled studies of roflumilast cream 0.3% in psoriasis patients.
In both studies, significantly greater percentages of roflumilast-treated patients achieved IGA success at Week 8, I-IGA Success, and an I-IGA status of Clear compared to vehicle alone. Roflumilast treatment significantly reduced psoriasis as indicated by PASI-75 and PASI-90, itch as indicated by the WI-NRS scale, body surface area (BSA) affected, and disease severity and burden as indicated by the Psoriasis Symptom Diary total score. Low rates of adverse events were seen, there were no treatment-related serious adverse events, and few patients discontinued treatment due to adverse events. In conclusion, once-daily roflumilast cream 0.3% demonstrated significant efficacy in the treatment of psoriasis in both trials, with onset of efficacy as early as 2 weeks. Roflumilast cream is an exciting topical nonsteroidal option with the potential to address shortcomings of currently available topical treatments for psoriasis.