SDDS 2020 - Day 3 Highlights - San Diego Dermatology Symposium

DAY 3 - DAILY SUMMARY
September 13, 2020

Chemical Peels: San Diego Dermatology Symposium® 2020 Highlights

Peter Rullan, M.D.

In his review of chemical peels, Dr. Rullan began with a reminder of the pre-peel evaluation (skin thickness, skin phototype, and goals of treatment) as well as skin prep, including topicals and antiviral prophylaxis. He emphasized the importance of patient comfort during and after a chemical peel, advocating for prescription analgesics for deeper peels as well as use of cold compresses, cooling devices, and soothing topicals. Dr. Rullan then began a review of chemical peels, ranging from very superficial to deep. He provided insight into his peels of choice for various dermatologic indications. For acne, he prefers 20-30% salicylic acid and Jessner’s, while for melasma he opts for 70% glycolic acid gel, 25% glycolic solution, 20-30% salicylic acid, or RevePeel Enlighten. For photo-aging, he prefers superficial-to-medium depth peels including trichloroacetic acid (TCA) 10-15% alone or Jessner’s + 10-15% TCA, or if opting for a true medium depth peel he uses Jessner’s + TCA 35% or a light phenol peel with croton oil 0.1% and phenol 30%. He also discussed spot treatment of actinic keratoses with croton/phenol or 50-60% TCA peels.

Dr. Rullan also discussed various aspects of deep chemical peels including certain cosmetic outcomes such as lip augmentation/eversion and upper eyelid tightening. With the addition of pre-operative clonidine, reduced use of epinephrine, and adequate pain control, Dr. Rullan has performed over 400 2-day phenol peels without cardiac complications such as arrhythmias. Finally, Dr. Rullan reviewed potential complications from chemical peels and stressed the importance of knowing your endpoints, using proper technique, and taking appropriate prophylactic measures to minimize these risks.

Preventative Skin Aging: San Diego Dermatology Symposium® 2020 Highlights

Ronald Moy, MD

Dr. Moy began his discussion on preventive skin aging with a brief review of the aging process, which involves loss of collagen types I and III and thinning of the skin as well as loss of muscle and subcutaneous fat. He then introduced the concept of hormonal influence in the above processes, explaining that hormones including estrogen, progesterone, dehydroepiandrosterone (DHEA), human growth hormone (HGH), and testosterone have been shown to influence skin thickness and elasticity. Regarding estrogen in particular, lower levels have also been correlated with numerous age-related diseases including Alzheimer’s, osteoporosis, heart disease, macular degeneration, and sexual dysfunction. Dr. Moy reviewed data on the safety of hormone replacement therapy (HRT), supporting the notion that estrogen + progesterone can be given safely without increased risk of breast cancer in women. He emphasized that bio-identical estrogen has superior safety compared to synthetic estrogen. Relatedly, studies have not found a relationship between testosterone supplementation and increased prostate cancer risk.

Proposed benefits of bioidentical hormone replacement on the skin include increased skin thickness and elasticity, increased epidermal hydration, reduced wrinkles, and enhanced content and quality of collagen. Dr. Moy explained that both positive and negative studies have been published on these points, but noted that the negative studies are somewhat limited in scope and design. Dr. Moy then briefly discussed skin cancer prevention with nicotinamide, topical DNA repair enzymes, and topical epidermal growth factors. He concluded that HRT therapy with bio-identical hormones is safe and can contribute to improved skin appearance.

Acne Scars: San Diego Dermatology Symposium® 2020 Highlights

Peter Rullan, M.D.

When it comes to acne scars, Dr. Rullan emphasizes the concept of “defect-oriented therapy,” in which the choice of therapy depends on the specific type of scar. Ice pick scars are best treated with chemical reconstruction of skin scars (CROSS), which can be done with either trichloroacetic acid (TCA) 30-60-90-100% or carboxylic acid 88%. Dr. Rullan prefers the latter because it has less risk of scar widening. A cotton tip applicator or fine tip brush can be used for spot treatment of individual scars, and in his experience this treatment can be performed in all skin types with minimal risk of post-inflammatory hyperpigmentation. For rolling scars, he recommends subcision as the treatment of choice, with the goal of “breaking the tethers” under the skin. He uses an 18- or 22-gauge cannula rather than the Nokor needle. For boxcar scarring, multiple treatment options exist including CROSS, microneedling, fractionated erbium or CO2 laser resurfacing, and even 2-day phenol chemabrasion for more severe, generalized scarring. Finally, for atrophic scars, filler remains the preferred treatment.

Dr. Rullan shared his sequential combination regimen for acne scars in all skin types, as follows: 1) CROSS, 2) tumescent anesthesia (using 20-gauge spinal needle), 3) subcision, 4) microneedling or fractionated erbium or CO2 laser, and 5) fillers (after 2-4 sessions of steps 1-4). He repeats this regimen every 1-3 months, for a total of 2-4 treatments.