John Jesitus

Natural skincare ingredients are always trending, noted Patricia K. Farris, MD, in her presentation at the 2021 Music City SCALE Symposium for Cosmetic Advances and Laser Education, held in Nashville, Tennessee. What’s making news now: using these ingredients in multifaceted formulations designed to perform in concert.

After 12 weeks, patients experienced an average 8% reduction in pigmented spots and statistically significant improvements in skin firmness vs baseline.

 Farris attributed these improvements to the skin lighteners, retinol, and peptides in Advanced Retinol Restorer.

Diamond nanoparticles in Precious Elixir Infusion Diamond (U.SK Under Skin), another part of the nightly study regimen, carry pentapeptide-35. This peptide, a sirtuin-1 analogue, acts similar to resveratrol, Farris noted.

The study’s morning regimen included Precious Elixir Infusion Pearl & Caviar (U.SK Under Skin). Although pearl- and caviar-based skin care may sound like marketing hype, she said, these ingredients provide genuine benefits. Pearl powder has a long history as a rejuvenating ingredient in Chinese medicine,

 providing tyrosinase inhibition (for skin lightening), antioxidant effects, and metal chelation. “It’s also a very good moisturizer,” Farris said. Caviar extract provides proteins, vitamins (A, B2, B6, B12, niacin, pantothenic acid, and folic acid), essential fatty acids, and minerals.

Also included in the study’s morning regimen: Advanced Defense Booster (U.SK Under Skin). Its key ingredients include ferulic acid, olive leaf extract, maslinic acid, trace minerals, and peptides. The complete regimen improved smoothness and dryness by 60% and 82%, respectively, vs baseline, according to Farris.


Besides protecting against sun damage, Farris said, certain antioxidants, like vitamin C, also boost collagen and lighten hyperpigmentation. Vitamin E provides antioxidant synergy with vitamin C. L-ascorbic acid needs to be formulated at a low pH, she noted, so adding peptides to vitamins C and E presents a formulation challenge. Accordingly, EverActive C&E + Peptide (AlumierMD) sequesters l-ascorbic acid crystals into a compartment that empties into the serum when the cap is pressed down.

“It’s an innovative way to keep the peptides and vitamin C separate until you mix the formulation,” she said. “It’s a 3-month supply broken down into 3 smaller 30-day supply units.”

In a 2-month, open-label trial, 71% of patients showed statistically significant improvement in wrinkling (8%-9%) over baseline (P < .05).

 Additionally, 68% of patients had significant improvement in periorbital isotropy, a measure of palmitoyl tripeptide-38’s impact on the dermal matrix, at 1 month.

Along with addressing complex skin care issues, Farris said, multi-ingredient formulations satisfy patients’ desire for simple regimens. “I’ve always been of that philosophy,” she said. “If you give people too complicated a regimen, their [adherence] goes down significantly.”

An effective regimen could be as easy as 1 morning product and 1 evening product (excluding cleansers and toners) or, Farris noted, “as complicated as 2 or 3 products that might be layered together.” She said that in her experience, the sweet spot is 2 or fewer morning and 2 or fewer evening products: “The simpler the regimen, the better.”

Farris has been a speaker, investigator, or adviser for Alastin, CeraVe, Johnson & Johnson Consumer Health, La Roche Posay, NeoStrata, SkinCeuticals, and U.SK Under Skin.

Farris PK. Next generation cosmeceuticals. Presented at: Music City SCALE Sym- posium for Cosmetic and Laser Education; August 18-22, 2021; Nashville, TN.

Farris P, Draelos ZD, Felipe de Oliveira Stehling L. Novel facial treatment regi- men improves aging skin appearance. 

 2021;20(3):274-278. doi:10.36849/JDD.5791

Shao DZ, Wang CK, Hwang HJ, Hung CH, Chen YW. Comparison of hydration, tyrosinase resistance, and antioxidant activation in three kinds of pearl powders. 

Lintner K, Gerstein F, Solish N. A serum containing vitamins C&E and a matrix-repair tripeptide reduces facial signs of aging as evidenced by Primos analysis and frequently repeated autoperception. 

2020;19(12):3262- 3269. doi:10.1111/jocd.13770

Articles

Natural skincare ingredients are always trending, said Patricia K. Farris, MD, hear what she had to say about using these in combination with other regimens.

Combination Approaches Drive Cosmeceutical Regimens

A recent case report highlights the importance of caution when using fractional laser resurfacing in patients with active or previous acne, the report authors said. “We had a patient with mild comedonal acne who developed a severe acne agminate-like granulomatous reaction after rejuvenation laser therapy,”

 principal investigator Ifa Etesami, MD, MPH, told 

. She is an assistant professor in the Department of Dermatology at Razi Hospital, Tehran University of Medical Sciences, Iran. Along with carefully examining for acne in patients requesting laser rejuvenation, the authors recommend using deep bulk-heating rejuvenation lasers cautiously in the presence of acne lesions, or thoroughly treating the acne before laser therapy.

The case report was published online May 4 in the 

 To the best of the authors’ knowledge, theirs is the first report of such a reaction to minimally invasive fractional laser rejuvenation. 

The 41-year-old woman underwent Fotona4D laser rejuvenation with the SP Dynamis dual-wavelength laser system (1064-nm Nd:YAG and 2940-nm Er:YAG; Fotona). At the time of treatment, she had mild inflammatory acne limited to her neck and chin. Her medical history was unremarkable except for adolescent acne, which was treated with isotretinoin for 8 months.

Perioperatively, the patient cleaned her face with a facial cleanser, after which the treatment area was cleaned with 70% ethanol solution. She underwent 1 laser session and began herpes prophylaxis immediately thereafter.

Three days postoperatively, the patient developed severe erythematous papules on her face and neck. One week post treatment, the lesions had evolved into monomorphic pustules. Tzanck smear ruled out the presence of herpes. Further investigation uncovered gram-positive cocci that culture revealed to be Staphylococcus epidermidis. This entity is rarely pathogenic, and authors considered it to be part of the patient’s normal skin flora.

The lesions did not respond to tetracyclines, cephalexin, or ciprofloxacin. After around 2 weeks, the lesions began to scale off and evolve into infiltrated edematous, erythematous papules. 

Punch biopsy performed 3 weeks post laser showed ill-defined small granulomas—composed of histiocytes, small lymphocytes, and multinucleated giant cells without necrosis—in the superficial dermis. The infiltrate extended to the deep dermis and congregated around the follicles; the overlying epidermis showed mild acanthosis and spongiosis. Together, authors said, histological findings pointed to acne agminate. This condition usually affects young adults, with lesions occurring predominantly in the central face.

The patient experienced no systemic symptoms during the reaction. Laboratory tests including complete blood count, lipid profile, erythrocyte sedimentation rate, and renal and liver function were normal, as were viral markers, purified protein derivative/tuberculosis testing, and angiotensin-converting enzyme and calcium levels. Over time, the infiltrated papules resolved without therapy. By 2 months post treatment, the patient’s skin had completely recovered.

“Acne agminate is a relatively rare granulomatous condition with unknown etiology,” Etesami says. However, it may represent a form of granulomatous rosacea or a granulomatous reaction to ruptured hair follicles.

 Nishimoto et al showed that cell-mediated granulomatous immune reaction in acne agminate could occur following the entrance of Propionibacterium acnes into the dermis due to follicular rupture.

 Some authors have suggested that acne agminate is a granulomatous reaction to Demodex folliculorum, ruptured epidermal cysts, or aluminum zirconium complexes.

Etesami said, “We believe that the bulk heating of the skin caused by the laser may have led to the rupture of existing comedones in our patient, leading to the entrance of Propionibacterium acnes and other particles of follicles into the dermis, resulting in a granulomatous reaction and acne agminate-like lesions.” Infections or biofilm may have aggravated the patient’s condition, she added, but the preoperative facial cleansing and negative culture from lesions argue against these possibilities.

The laser settings used were not particularly aggressive, said Etesami. “We believe that the Fotona 4D third step, which uses 1064-nm Nd:YAG with high fluences and high pulse duration (2 seconds), contributed most to the severe reaction in our patient.” The third step is performed to achieve deep and homogenous bulk heating of the skin, she said. However, Etesami added, performing this step in skin with existing comedones could have led to the rupture of the follicles and the subsequent severe granulomatous inflammation.

“Complications of resurfacing fractional lasers are rare, and these lasers are considered safe,” she said. “It’s also important to note that in our laser clinics at Razi Hospital, the Fotona 4D laser has been applied to hundreds of patients during recent years without any significant [adverse] effects [AEs].”

However, Etesami said, many studies report acneiform lesions as one of the most frequent AEs after laser therapy. In a study of 730 patients who underwent fractional rejuvenation with 1927-nm, 1550-nm, or CO2 laser, 13 patients experienced acne eruptions.

 In a retrospective study of 961 patients who underwent 1550-nm Er:YAG laser treatment, 7.6% experienced complications, with acneiform lesions (1.87%) being the most common.

 A review of all reported complications of fractional laser resurfacing occurring between 1998 and 2009 revealed that acneiform lesions occurred in 2% to 10% of patients.

 Conversely, authors uncovered only 1 previously reported case of granulomatous lesions occurring after laser resurfacing.

Ultimately, authors advised caution in patients considering laser therapy who have active comedonal acne or a history thereof. “I would highly suggest dermatologists first treat comedonal acne lesions in patients seeking minimally invasive rejuvenation lasers before performing laser therapy,” Etesami said. “Even very mild comedonal acne, as in our patient, can lead to severe reactions including acne flare or the development of an acne agminate-like granulomatous reaction.”

1. Balighi K, Abedini R, Ghanadan A, Peymanfar AA, Akhdar M, Etesami I. Self-limited acne agminate-like granulomatous reaction to facial laser rejuvenation in a patient with comedonal acne vulgaris. J Cosmet Laser Ther. 2020;22(6-8):241-243. doi:10.1080/14764172.2021.1921810

2. Ferguson L, Fearfield L. Topical dapsone gel is a new treatment option for acne agminata. Clin Exp Dermatol. 2019;44(4):453-455. doi:10.1111/ced.13742 

3. Nishimoto J, Amano M, Setoyama M. The detection of Propionibacterium acnes signatures in granulomas of lupus miliaris disseminatus faciei. J Dermatol. 2015;42(4):418-421. doi:10.1111/1346-8138.12773

4. Ganzetti G, Giuliodori K, Campanati A, Simonetti O, Goteri G, Offidani AM. Doxycycline-isoniazid: a new therapeutic association for recalcitrant acne agminata. Dermatol Ther. 2012;25(2):207-209. doi:10.1111/j.1529-8019.2012.01442.x

5. Cohen SR, Goodacre A, Lim S, et al. Clinical outcomes and complications associated with fractional lasers: a review of 730 patients. Aesthetic Plast Surg. 2017;41(1):171-178. doi:10.1007/s00266-016-0767.x 

6. Graber EM, Tanzi EL, Alster TS. Side effects and complications of fractional laser photothermolysis: experience with 961 treatments. Dermatol Surg. 2008;34(3):301-305; discussion 305-307. doi:10.1111/j.1524-4725.2007.34062.x 

7. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing treatment complications: a review. Dermatol Surg. 2010;36(3):299-306. doi:10.1111/j.1524-4725.2009.01434.x

8. Rendon-Pellerano MI, Lentini J, Eaglstein WE, Kirsner RS, Hanft K, Pardo RJ. Laser resurfacing: usual and unusual complications. Dermatol Surg. 1999;25(5):360-366; discussion 366-367. doi:10.1046/j.1524-4725.1999.07358.x 

Etesami reports no relevant financial disclosures.

A recent case report highlights the importance of caution when using fractional laser resurfacing in patients with active or previous acne.

Rejuvenating Laser Leads to Acne Agminate-Like Reaction

Many current laser and light-based technologies are well suited for treating patients with skin of color and pregnant patients—2 populations that typically require caution, experts in these therapies told 

. Future directions for light-based therapies may involve a 1726-nm laser for acne, advanced applications for photodynamic therapy (PDT), and new ways of seeing skin cells including cancers.

Patients commonly ask whether cutaneous lasers are safe to use during pregnancy, said Jill S. Waibel, MD, a Miami, Florida-based dermatologist in private practice. Babies form most vital structures during the first trimester, she said, and typically only medically necessary treatments of any modality—oral medication, surgical, intravenous, or laser—would be performed at this time. “However, after that first trimester, it could be argued that lasers would possibly be safer than an oral or topical medication that may enter bloodstream and reach the fetus,” Waibel said.

In a review of 380 pregnant females treated with various lasers across all trimesters, the only adverse event reported was 1 case of premature rupture of membranes possibly related to laser therapy.

 Another recent review highlights the utility of nonsurgical treatments including lasers for postpartum abdominal rejuvenation.

“Many women typically have stretch marks after pregnancy, so there’s an opportunity shortly after delivery to target the stretch marks while they’re still red with a pulsed-dye laser, followed by a nonablative fractionated laser to address the atrophic skin that we find in stretch marks,” said review coauthor Sabrina G. Fabi, MD, a San Diego, California-based dermatologist in private practice.

Fabi treats such patients as early as 6 weeks postpartum. “It’s hard to juggle being able to come into my office when they’re caring for a newborn at home, but I find the earlier the better,” she said.

For postpartum skin laxity, Fabi often follows the foregoing laser treatments with microfocused ultrasound. A study by Lin et al showed that when performed 6 to 24 months postpartum, such treatments can significantly contract loose skin post pregnancy.

Waibel added, “There are 3 different types of striae—striae rubra, striae alba, and striae distensae. The type of striae determines which laser therapy we choose.” For striae rubra, she said, pulsed-dye laser and nonablative fractional lasers work well. For striae alba, she tends to use nonablative fractional or ablative fractional laser, with laser-assisted delivery of bimatoprost. “Striae distensae are the toughest to treat. We use fractional ablative laser and laser-assisted delivery of poly-L-lactic acid,” she explained.

In 2021, dermatologists have many laser and energy devices that can treat all skin types safely and effectively. “Lasers treat many skin conditions including keloids, acne scars, hair removal, tattoos, pigmentary alterations, and photorejuvenation,” Waibel said. One of the challenges is that many patients are not aware of the advances in lasers over the past 2 decades, or they are told by their physicians that lasers are not safe for their skin type.

42-year-old Black woman with café au lait birthmark before and after 1 treatment with 1064-nm picosecond laser (Lumenis).

In April 2021, Accure Acne, Inc, Boulder, Colorado, launched a private investment offering to raise up to $20 million to support development of the Accure Laser System. It uses a 1726-nm fiber laser to destroy sebaceous glands.

In March 2020, Accure’s exclusive manufacturing partner for the product, Quanta Systems SpA, Milan, Italy, received CE Mark certification to market what, according to Accure, is the only 1726-nm laser with CE Mark clearance for acne. In the United States, preliminary results of the company’s IRB-approved FACE trial demonstrated an average lesion reduction of 80% 3 months post treatment.

Regarding other acne-targeting technologies, R. Rox Anderson, MD, said that photodynamic therapy works well. However, he said, patients typically cannot tolerate the downtime and inflammatory reactions, and the lengthy procedure does not fit well into a busy practice.

Anderson is Lancer Endowed Chair in dermatology and director of the Wellman Center for Photomedicine at Harvard Medical School in Boston, Massachusetts. He also serves as founder, and chief scientific and medical officer of Accure Acne.

A system involving gold-coated microparticles to improve sebaceous-gland targeting with lasers (Sebacea Microparticles; Sebacia) has stalled. The rationale behind the microparticles, he said, is to force light-absorbing material backward into the gland, then target it with laser pulses for selective photothermolysis. The technology earned marketing clearance in Europe and the United States, Anderson said, and a European real-world trial went well; however, the US equivalent did not.

 “The sebaceous gland is like a lung that never inhales. It only exhales—there’s a duct, and it goes to the surface,” Anderson said.

“The gold nanoparticle concept worked very well, and if you had a hair-removal laser, wavelengths 755-nm alexandrite, 800-nm diode, or 1064-nm Nd:YAG, you only needed to purchase the nanoparticles. The treatment is easy to apply and the data are very compelling,” Waibel said.

The European postmarketing studies, in which investigators pretreated patients with a retinoid to open pores, showed after 3 in-office treatments that inflammatory acne decreased 74% at 6 months, 85% at 12 months, and 92% at 24 months.

 “Sadly,” Waibel said, “the company had a great product and great leadership, but the economics led to the close of the company during the pandemic.”

Latino patient with severe melasma before and after 1 treatment with intense pulsed light, 1927-nm laser, and tranexamic acid 650-mg half-tablet twice a day.

Outside of acne, Anderson said, red-light PDT remains a mainstay treatment for actinic keratoses (AKs) and field cancerization. “There’s a fair amount of evidence that aminolevulinic acid (ALA)-PDT with red light will greatly suppress future carcinogenesis.”

Therefore, PDT merits a place alongside 5-fluorouracil and other noninvasive AK treatments. “There’s strong synergy between the vitamin D analogs and both 5-fluorouracil and photodynamic therapy,” he adds.

For the future, Anderson finds nononcologic applications of PDT intriguing. Having a heavily pediatric practice, he frequently sees children with large nonresectable nevi sebaceous. Nevus sebaceous lesions are often very thick, he said. “Sebaceous glands, including the abnormal ones in nevus sebaceous, are very avid for the porphyrin pathway. So, if you get the ALA to them, they will very potently photosensitize themselves,” Anderson said.

“Optical diagnostics is a tsunami coming our way,” Anderson said. “I don’t know when. But we will have clinical tools that are worth using. For things like Mohs surgery, it’s a game changer.”

To optimize outcomes, Anderson explained, virtually every skin cancer and benign lesion that dermatologists now biopsy should be viewed microscopically. “I would love to be able to do the analysis at the bedside—like 1-stop shopping.”

Optical coherence tomography (OCT) involves splitting a light source and sending half of it to the skin and the other half to a reference mirror. This technology can penetrate up to 1.5 mm or sometimes 2 mm. OCT provides lower resolution than its progenitor, reflectance confocal microscopy, according to Anderson. “You don’t see the single cells that you see with confocal microscopy.” However, OCT offers the ability to perform a fast, noninvasive “optical biopsy.”

Already, OCT has transformed retinal imaging. Guillermo “Gary” Tearney, MD, PhD, of the Wellman Center for Photomedicine at Massachusetts General Hospital in Boston, is applying this technology to gastrointestinal (GI) imaging. Fruits of these efforts include a small, tethered device that patients can swallow. “It does the equivalent of an upper gastrointestinal endoscopy series,” Anderson said.

Tearney has also invented a dynamic micro-OCT tool that one day could allow cellular-level skin imaging. Although typical OCT imaging is crude at this level, Anderson said, being able to examine rates of molecular diffusion within cells can provide a functional equivalent of staining.

“I believe we’re going to make a transformation where you get cellular resolution at sufficient depth, and functional information associated with the cell metabolic rate. Things like skin cancer are going to look very different with this type of imaging,” he said. Plus, imaging several square centimeters of tissue takes only seconds.

Meanwhile, Seok-Hyun “Andy” Yun, PhD, of the Wellman Center has discovered how to turn living cells into intracellular nanolasers by programming them to genetically express green fluorescent protein.

 The process involves hundreds of half- micrometer silicon disks. These intracellular laser particles (LPs) emit tunable subnanometer spectra at hundreds of wavelengths. “It allows you to tag individual cells with a laser that goes along with that cell,” Anderson said. 

Every time the cell divides, he explained, its LPs divide into the cytoplasm of its daughter cells. “And because you can make these lasers at so many different frequencies, you can track thousands of cells simultaneously.”

 In the future, Anderson said he will attempt to use intracellular nanolasers to develop tattoos that can be turned on and off.

1. Wilkerson EC, Van Acker MM, Bloom BS, Goldberg DJ. Utilization of laser therapy during pregnancy: a systematic review of the maternal and fetal effects reported from 1960 to 2017. Dermatol Surg. 2019;45(6):818-828. doi:10.1097/DSS.0000000000001912

2. Kream E, Boen M, Fabi SG, Goldman MP. Nonsurgical postpartum abdominal rejuvenation: a review and our experience. Dermatol Surg. 2021;47(6):768-774. doi:10.1097/DSS.0000000000003003

3. Lin FG. Nonsurgical treatment of postpartum lower abdominal skin and soft-tissue laxity using microfocused ultrasound with visualization. Dermatol Surg. 2020;46(12):1683-1690. doi:10.1097/DSS.0000000000002576

4. Tanghetti EA, Geronemus R, Bloom B, et al. Safety and efficacy data in a pilot study of the treatment of acne with a 1726 nm fiber laser. Presented at: American Society for Laser Medicine and Surgery 40th Annual Conference; May 1, 2020.

5. Anderson RR. What next? Stories from the Wellman Center. Presented at: Maui Derm; January 27, 2021; Maui, Hawaii.

6. Waibel JS. Gold microparticles and laser for the treatment of inflammatory acne vulgaris: European real-world outcomes. Presented at: American Society for Dermatologic Surgery Annual Meeting; October 24, 2019; Chicago, IL.

7. Bhatia AC. Acne vulgaris treatment with gold microparticles and laser pulses to achieve photothermolysis of sebaceous follicles in patients using topical retinoids. Presented at: American Society for Dermatologic Surgery Annual Meeting; October 24, 2019; Chicago, IL.

8. Morton CA, Szeimies RM, Basset-Seguin N, et al. European Dermatology Forum guidelines on topical photodynamic therapy 2019 part 1: treatment delivery and established indications - actinic keratoses, Bowen’'s disease and basal cell carcinomas. J Eur Acad Dermatol Venereol. 2019;33(12):2225-2238. doi: 10.1111/jdv.16017

9. Ameluz. Prescribing information. Biofrontera Inc; 1999.

10. Gather MC, Yun SH. Single-cell biological lasers. Nat Photonics. 2011;5:406-410. doi:10.1038/nphoton.2011.99

11. Martino N, Kwok SJJ, Liapis AC, et al. Wavelength-encoded laser particles for massively multiplexed cell tagging. Nat Photonics. 2019;13(10):720-727. doi:10.1038/s41566-019-0489-0

Waibel is a consultant, advisory board member, and clinical trial investigator for Candela; and an advisory board member for Sciton and Sebacia. She is also a consultant for and has received equipment loans from Lumenis.

Anderson is a consultant and/or adviser for Avaya, Blossom Innovations, Brixton, Cytrellis Biosystems, Follica, IPG, R2 Dermatology, and Sofregen Medical.

Innovations include underserved populations, acne, and advanced applications.

New Frontiers in Laser, Light, Optical Devices

Providing aesthetic procedures such as injectables and hair removal for lesbian, gay, bisexual, transgender, and queer (LGBTQ+) as well as sexual and gender minority (SGM) patients requires more than medical and aesthetic expertise, according to a panel of experts who spoke at the American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX) in April. Serving such patients also demands an understanding of consent and medical insurance issues unique to these populations, they explain.

Even modest changes in a transgender, or gender transitioning, patients’ self-perception can deliver major quality-of-life (QOL) improvements, said Lauren Meshkov Bonati, MD, a dermatologist in private practice at Mountain Dermatology with offices in Edwards and Frisco, Colorado.

“It’s important for us to recognize that gender dysphoria is a classified diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5),” Meshkov Bonati said.

Gender dysphoria is categized as a feeling of distress that may occur in those whose gender identity differs from their sex assigned at birth or sex-related physical characteristics, according to Mayo Clinic.

Additionally, anywhere from 700,000 to 1.4 million Americans self-identify as transgender, she added.

As with any patient community, caring for LGBTQ+/SGM patients requires an understanding of that population’s holistic needs. Dermatologists should be cognizant of the fact that suicide rates among transgender individuals greatly outpace those in the general population—41% vs 4.6%, respectively—and that QOL improves for transgender people who have undergone transition, Meshkov Bonati said.

“What does that mean for a dermatologist who’s not performing these types of surgeries?” she asked. “We know that there are approaches that we can use to help the patient achieve a more masculine or feminine appearance. We as cosmetic dermatologists can employ an injectable strategy that will enhance masculine or feminine features for the purpose of helping relieve the gender incongruity that transgender patients feel.”

To explore the QOL impact of injectable treatments in transgender individuals, Meshkov Bonati and colleagues undertook a pilot trial involving 9 patients who had not previously undergone injectable treatments. The trial used a metric called the Gender Continuum Self-Perception Scale, which enabled patients to pinpoint their gender self-perception before and after treatment compared to societal male and female ideals.

“Subjects overall desired to look from 65% to 100% more masculine or feminine than they did at the moment,” she said.

 “However, 8 of 9 patients said they would be happy looking equally or even less gendered than what they considered society’s ideal.” 

These patients were realistic in her view, she continued. “They didn’t have wild expectations of having a brand-new forehead or jawline,” said Meshkov Bonati. “They understood that injectables can’t accomplish the dramatic results that can be achieved with surgery. So we shouldn’t be afraid to treat these patients.”

Posttreatment, patients achieved an average 44% shift toward gender ideals. Three patients flipped their gender perception completely from male to female or vice versa. Global Aesthetic Improvement Scale and Dermatology Life Quality Index results mirrored these findings. “Most patients reported reduced self-consciousness and embarrassment,” Meshkov Bonati said.

Even more telling were the patients’ comments, she added. For example, one subject reported that friends noticed they were posting more frequently on social media. Other patients reported feeling more comfortable in gender-specific clothing and hairstyles. “One patient said, ‘I’m not sure if it’s the treatment itself or just knowing that I’m doing something that makes a difference.’ That’s what this is all about: empowering transgender individuals so that they feel more in control of their gender and how they’re feeling, improving quality of life, and reducing suicidality.”

Because World Professional Association for Transgender Health (WPATH) standards of care

 fail to address noninvasive or reversible gender-affirming procedures, a recent paper by Waldman et al recommends establishing such standards, particularly for transgender teens.

 “It’s an open field out there,” Meshkov Bonati said. And dermatologists have the opportunity to set such standards, which may include allowing mature teens to consent to reversible procedures, she adds.

Untreated gender dysphoria may lead to anxiety and depression that persist throughout adulthood, Meshkov Bonati noted. “That’s a huge burden of disease that could potentially be prevented.”

Accordingly, she said injectable interventions for transgender patients should not be viewed as cosmetic. “This isn’t the 65-year-old woman who comes in complaining of marionette lines or brown spots on her face. These are individuals who very deeply know that they are in the wrong body,” Meshkov Bonati said.

With this in mind, she said injectable treatments are crucial to patient dignity. “It’s medically necessary, ethical care that will help adolescents affirm who they are,” Meshkov Bonati added. If dermatologists do not provide safe, ethical, accessible care, she cautioned that transgender patients will seek treatment elsewhere, sometimes with disastrous results.

One day, minimally invasive aesthetic treatments might be considered part of the pretreatment regimen required before gender-reassignment surgery, she said, adding, “Perhaps injectables are something we can use as a way to help the patient dip their toe in and see how it feels to start transitioning physically.”

As insurers’ willingness to cover hair removal for transgender patients grows, so will dermatologists’ role in securing coverage, said Erica D. Dommasch, MD, MPH,

 a dermatologist at Beth Israel Deaconess Medical Center and an assistant professor of dermatology at Harvard Medical School, both in Boston, Massachusetts.

In a study coauthored by Dommasch, 4.6% of 174 policies analyzed covered permanent hair removal without restrictions. According to the authors, the remaining 166 policies (95.4%) broadly excluded or did not mention gender-affirming care; prohibited coverage of hair removal or did not mention it; or only permitted coverage of hair removal preoperatively for genital surgery. Dommasch reported that 26% covered only preoperative hair removal for genital surgery; and 28.7% had no policies regarding transgender hair removal.

The ACA marketplace policies in states without transgender care protections were less likely to cover hair removal without restrictions than ACA policies in states with protections—2 of 85 policies (2.4%) in states without transgender care protections vs 5 of 38 policies (13.2%) in states with transgender care protections, and Medicaid policies were less likely to cover preoperative or nonsurgical hair removal compared with ACA policies—6 of 51 Medicaid policies (11.8%) vs 47 of 123 ACA policies (38.2%).

“Anecdotally, [insurance] coverage seems to be getting a little better over time,” she said. “Many insurance plans will cover permanent hair removal preoperatively, especially if they are covering the gender-affirming surgery.” Some insurers may occasionally cover hair removal in aesthetic areas such as the face, added Dommasch, who also works part time at Fenway Health, a Boston-based community health center that specifically serves the LGBTQ+ community.

Laser hair removal (LHR) is FDA-approved for permanent hair reduction. Additionally, electrolysis is approved for hair removal because it reduces the number of hair follicles. The FDA’s distinction between permanent hair reduction and removal does not mean that electrolysis is more effective than laser hair removal, said Dommasch. “In fact, probably the contrary is true.”

Many transgender patients require presurgical hair removal to prevent complications such as urinary retention and infections after gender-affirming surgery (GAS). Phalloplasty, the most common type of GAS used in transmasculine patients, involves creating a neophallus using skin flaps from the medial forearm or anterolateral thigh, both of which may need presurgical hair removal.

Creating a neovagina for transfeminine patients typically involves skin from the penile shaft or scrotum, the latter of which typically requires hair removal. “Areas of the scrotum that may be treated include either the midline, if using a pedicled scrotal flap, or entire scrotum, for free scrotal skin full-thickness grafts,” Dommasch said.

Because patients typically require 6 to 12 months of hair removal before undergoing GAS, she advised that it is crucial for dermatologists to confirm with patients and surgeons which genital areas and donor sites require treatment long before surgery. “This can be done via photos or permanent ink markings of the sites. Keep in mind that the surgeon may want more than one site treated—they may want both forearms or legs treated,” she said.

In a recent study, 56% of patients undergoing phalloplasty consults had forearm tattoos.

 If patients choose skin flaps from tattooed areas, that means the neophallus is going to have a tattoo,” Dommasch explained. Additionally, tattoos can interfere with LHR. “If patients choose to use the forearm site, and they have a tattoo, these patients may need electrolysis for these areas.”

Dermatologists serving transgender patients must know that securing prior authorizations (PAs) for hair removal will be time-consuming and may require dedicated staff, she said. “Keep trying,” she said. “These policies are continually changing. Insurers are very confused about what they should and should not cover in the context of gender-affirmation surgeries.”

Accordingly, Dommasch recommended becoming familiar with policies of the most common private insurers in the practice’s area—especially Medicaid—and creating templated PA letters tailored to each insurer. Where possible, these letters should mirror language used in specific policies. She added that before covering presurgical hair removal, many insurers require documenting that patients have met all applicable WPATH criteria,

Regarding billing, she suggested having a price list available for all potential hair removal sites. “Many insurers will pay a standard percentage of the asking price,” Dommasch said, while also recommending tracking reimbursement rates so that one can set prices commensurately. “Remember, if you increase your price for these patients, you may be increasing the price for patients who pay out of pocket,” she said. Dermatologists may bill permanent hair removal with CPT code 17999, unlisted skin procedure, which has no standard negotiated price.

“Looking forward, dermatologists are going to be very important in ensuring affordable, safe access to hair removal,” Dommasch said. “We need to work closely with policy makers, insurance companies, and other stakeholders. Hopefully, down the road we will get designated CPT codes for these gender-affirming procedures, and hair removal as well, which will make everyone’s life easier.”

Meshkov Bonati’s study was funded by Allergan. Dommasch reported no relevant conflicts of interest.

1. Peebles JK, Dommasch ED, Meshkov Meshkov Bonati L, et al. LGBTQ/SGM health in dermatology: updates & pearls in a changing landscape. Presented at: American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX), April 23-25, 2021. Virtual.

2. Meshkov Bonati LM. Gender-affirming procedures: injectables. Presented at: American Academy of Dermatology 2021 Virtual Meeting Experience. April 23-25, 2021. Virtual.

3. Gender dysphoria. Mayo Clinic. December 6, 2019. Accessed June 15, 2021. https://www.mayoclinic.org/diseases-conditions/gender-dysphoria/symptoms-causes/syc-20475255

4. Herman JL, Haas AP, Rodgers PL. Suicide attempts among transgender and gender non-conforming adults. American Foundation for Suicide Prevention. 2014. Accessed May 26, 2021. https://escholarship.org/uc/item/8xg8061f

5. Meshkov Bonati L, Petrell K, MacGregor J, Kandula P, Dover JS, Kaminer MS. The effects of neurotoxin and soft tissue fillers on gender perception in transgender individuals: a pilot prospective survey-based study. Published online March 5, 2021. J Am Acad Dermatol. doi:10.1016/j.jaad.2021.02.080

6. World Professional Association for Transgender Health. Standards of care for the health of transsexual, transgender, and gender-conforming people. 7th version. 2012. Accessed May 26, 2021. https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English2012.pdf?_t=1613669341

7. Waldman RA, Waldman SD, Grant-Kels JM. The ethics of performing noninvasive, reversible gender-affirming procedures on transgender adolescents. J Am Acad Dermatol. 2018;79(6):1166-1168. doi:10.1016/j.jaad.2017.12.052

8. Dommasch E. Hair removal: review and updates in transgender health. Presented at: American Academy of Dermatology 2021 Virtual Meeting Experience (AAD VMX). April 23-25, 2021.

9. Thoreson N, Marks DH, Peebles JK, King DS, Dommasch E. Health insurance coverage of permanent hair removal in transgender and gender-minority patients. JAMA Dermatol. 2020;156(5):561-565. doi:10.1001/jamadermatol.2020.0480

10. Zhang WR, Garrett GL, Arron ST, Garcia MM. Laser hair removal for genital gender affirming surgery. Transl Androl Urol. 2016;5(3):381-387. doi:10.21037/tau.2016.03.27

11. Benson TA, Boskey ER, Ganor O. The effect of forearm tattoos on flap choice in transmasculine phalloplasty patients. MDM Policy Pract. 2020;5(1):2381468320938740. doi:10.1177/2381468320938740

Dermatologists are expanding their skill sets and exploring new techniques to enable gender-diverse patients to achieve their medical and aesthetic goals.

Aesthetic Treatments Benefit Gender-Diverse Patients

Trichoscopy (a dermoscopy-based diagnostic method) not only helps diagnose hair disorders and monitor treatment but also predicts treatment efficacy, Anna Waśkiel-Burnat, MD, PhD, a dermatologist at Medical University of Warsaw in Poland, said at the 29th European Academy of Dermatology and Venereology Virtual Congress (EADV).

“There are numerous hair and scalp diseases that share similar clinical features,” Waśkiel-Burnat said in her presentation. “Trichoscopy is an easy-to-perform diagnostic method that may help identify subtle details and establish the correct diagnosis. For example, it is difficult to distinguish between female androgenetic alopecia (FAGA) and fibrosing alopecia in a pattern distribution (FAPD) based only on the clinical picture. In these conditions, trichoscopy is useful to avoid misdiagnosis.”

Features of FAGA include increased numbers of vellus hairs and single-hair follicular units, along with anisotrichosis and yellow dots. For a diagnosis of FAGA, patients must meet 2 of the following major criteria

More than 4 yellow dots in 4 images at 70-fold magnification in the frontal area

Lower average hair thickness in the frontal area compared with the occiput (calculated from at least 50 hairs from each area).

More than 10% thin hairs (< 0.03 mm) in the frontal area

Alternatively, dermatologists can establish a diagnosis of FAGA using 1 major criterion and 2 of the following minor criteria (all comparing frontal area with occiput):

3.1 ratio of hair follicles with perifollicular discoloration

“Another condition that is difficult to diagnose, even with trichoscopy, is alopecia areata [AA] incognita,” Waśkiel-Burnat said. Because this entity is frequently misdiagnosed as telogen effluvium, histopathological examination is important, she said.

Because it is challenging to identify patients with AA who are at risk of rapid disease progression and to determine which patients are likely to respond well to immunosuppressive therapy, Waśkiel-Burnat and colleagues developed the Alopecia Areata Predictive Score.

In a study of 65 patients with patchy AA, the authors conducted trichoscopic examinations at baseline and 2 months after treatment initiation. After 6 months of treatment, investigators classified 27 patients as responders and 38 as nonresponders. Positive predictive trichoscopic factors (observed in control trichoscopy) for hair regrowth in patchy AA included upright regrowing hairs and pigtail hairs.

 Negative predictive markers for hair regrowth included black dots, broken hairs, exclamation mark hairs, and tapered hairs. Probability of regrowth ranged from 98.3% for patients with the highest AA predictive score to 0% for patients with the lowest score.

For alopecia totalis or alopecia universalis, Waśkiel-Burnat said, she recommends trichoscopic examination 6 weeks after starting treatment and clinical assessment of hair regrowth after 4 months’ treatment. Positive predictive factors (observed in control trichoscopy) for regrowth in patients include pigmented vellus hairs and pigmented upright regrowing hairs. No negative predictive markers are associated with these conditions, she added.

Findings in a recent analysis showed lichen planopilaris accounted for 7.6% of visits to 22 specialist hair clinics.

 This condition is characterized by perifollicular scaling and erythema, as well as white dots and milky red and white areas on the scalp.

Trichoscopy can be performed with or without immersion fluid (wet vs dry trichoscopy). “It is important to start the trichoscopy examination using the dry method, as it allows one to better visualize scaling and features of blond and gray hairs,” Waśkiel-Burnat said. She suggests performing trichoscopy after hair dyeing for light tones since dark hair is more easily.

“In the future, I believe that trichoscopy will focus on general medicine and its usefulness in diagnosis of nondermatological conditions such as connective tissue disorders and hematological diseases,” she said.

Waśkiel-Burnatreports no relevant disclosures or financial interests.

1. Waśkiel-Burnat A. Trichoscopy in hair. 29th European Academy of Dermatology and Venereology Virtual Congress; October 29-31, 2020.

2. Rakowska A, Slowinska M, Kowalska-Oledzka E, Olszewska M, Rudnicka L. Dermoscopy in female androgenic alopecia: method standardization and diagnostic criteria. 

. 2009;1(2):123-130. doi:10.4103/0974-7753.58555

3. Waśkiel-Burnat A, Rakowska A, Kurzeja M, et al. The value of dermoscopy in diagnosing eyebrow loss in patients with alopecia areata and frontal fibrosing alopecia. 

. 2019;33(1):213-219. doi:10.1111/jdv.15279

4. Waśkiel-Burnat A, Rakowska A, Sikora M, Olszewska M, Rudnicka L. Alopecia areata predictive score: a new trichoscopy-based tool to predict treatment outcome in patients with patchy alopecia areata. 

. 2020;19(3):746-751. doi:10.1111/jocd.13064

5. Vañó-Galván S, Saceda-Corralo D, Blume-Peytavi U, et al. Frequency of the types of alopecia at twenty-two specialist hair clinics: a multicenter study. 

. 2019;5(5):309-315. doi:10.1159/000496708

According to one expert at the 29th EADV Virtual Congress, trichoscopy not only helps diagnose hair disorders and monitor treatment but also predicts treatment efficacy.

Trichoscopy Aids Diagnosis, Prognosis

In making consumer decisions, says an expert who spoke at The Cosmetic Bootcamp (CBC) last year in Aspen, Colo., women gravitate toward authenticity — which is often politically incorrect and funny.

Everyone has a story, says Gina Barreca, Ph.D. "And that's how you want to reach them." She is Board of Trustees Distinguished Professor of English at the University of Connecticut.

Vendor and physician marketing reflects that healthcare providers are striving for authentic messaging, she says, but perhaps these efforts don't go far enough. "Many of the stories that women have are funny, and they're not read by the world as funny."

Women and men think and communicate differently, says Dr. Barreca, who reveals her age and weight at the outset of any speaking engagement to eliminate guesswork. "The first thing that especially women want to know about other women who are at the front of the stage is how old you are." Without this information, she says, women endeavor feverishly to figure it out, distracting themselves from the speaker's message.

Women also try to guess each other's weight, adds Dr. Barreca. If someone won't tell, she says, women attempt to triangulate this information by asking what size clothing the person wears. The answer often varies by brand. "In an Armani, I'm 12. At Dot's Dress Barn, I'm a 22. Women know that the more we spend on our clothing, the smaller the size we will be. Men do not have that issue."

Additionally, women often set goals such as dieting down to size two for their son's wedding or daughter's bat mitzvah. "You would never hear a man say, 'I'm going to be a 42 short by the holidays.'"

Dr. Sigmund Freud believed he could never answer the question of what women want. After touring the CBC exhibit hall, jokes Dr. Barreca, she wants everything at every booth. On a serious note, she says that after talking to vendor representatives about the science behind their offerings, she realizes their rhetoric has changed. "Now it's all about strength, it's not about beauty. It's really about looking at how women's strength comes from beauty, how those two things are twins."

Dr. Barreca says that when she was growing up, people spoke and thought of beauty in terms of the classic Disney princess — a frail waif who waited on help from others. "She had a tiny waist, and mostly what she did was fall over, pass out. Beautiful meant weak. Beautiful now means strong."

Dr. Barreca says that when her female friends heard she was attending CBC, they had one question: what could they do to battle unwanted age-related changes in their appearance? With current aesthetic medical technology, she says, doctors can do everything. “They can take things away; they can put things back. They can remove things and replace them. Everybody wants a shortcut. Everybody wants to look good. Nobody looks dispassionately at his or her own picture. Every photograph that you see yourself in, you see yourself in a different angle. Nobody's ever said, 'oh well, that's just some lady. That's just some guy.' We see ourselves. Every photograph is a mirror."

This dynamic is hard to escape, she says. Pictures of natural wonders from someone's vacation might occasionally be intriguing, says Dr. Barreca. "But who really wants to look at photos without you in them? We want to look at ourselves. We have to tell our stories."

Dr. Barreca says that whenever she tells stories, in print or in person, she focuses on humor. And there's a very specific difference between men's humor and women's humor, she adds. "Women don't tell jokes. When a woman says, 'I have something funny to tell you,' if you're smart, you'll sit down. You're going to be there a long time, because a woman is not going to tell you a joke. She's always telling you a story. And she's going to tell you a story that happened to her in her real life."

Men typically know two pieces of information about their best friends — their first name and what kind of vehicle they drive, Dr. Barreca quips. Conversely, she says, women tell their stories by revealing the most exquisite pieces of personal detail, often on first meeting each other. "You sit next to a woman for more than 13 seconds, you know if she's in a relationship; if the relationship is any good; does she have kids; how are the kids; are they in public or private school? And if you talk to her through two courses of a meal, you know if she's taking estrogen orally or through a patch."

In contemporary culture, Dr. Barreca says, women need to make up their own stories. "One of the things I talk about is the way that women and our bodies really work." A couple years ago, her students were talking about the bikini bridge — the notion that when a woman lies on her stomach on the beach, there should be visible space between her torso and the top of her bikini bottom. "It turned out to be a hoax. My bikini bridge is the Verrazano. It has 12 lanes and takes an EZ Pass. Real humor comes from telling stories."

And real stories, she says, are the only kind that elicit women's real laughter — not the tinkling bell-like tone one often hears at dinner parties. "No woman has ever made that sound when she's having a good time. When a woman laughs in this way, she's thinking, 'on the way home, I need Bounty towels. Is that five for $4, or four for $5?'"

By embracing laughter and telling their stories, says Dr. Barreca, women can rearrange how they look at the world and how the world looks at them. Anita Loos once said diamonds are a girl's best friend. "I think it's the other way around. Your best friends, male or female, are your diamonds." Like diamonds, she explains, real friends are unmistakable, invaluable and, when needed, tough enough to cut glass.

Gina Barreca PhD. "What Woman Want — The Ideal of Beauty, the Concept of Aging, and the Psychology of the Female Consumer," 

Women are the majority who undergo aesthetic procedures, and key to reaching them, according to Dr. Gina Barreca, is knowing what they want.