Aesthetic Dermatology

Women seeking genital surgery to reduce the size of their labia minora do not have large or misshapen labia, and also tend to be relatively young, a small U.K. study has found.

Of the 33 women in the prospective study, published Aug. 24 in BJOG, 30 had labia with dimensions within the normal published limits, yet sought surgery anyway. The women’s average age was 23 years, although a quarter were 16 years or younger, with the youngest being 11 years old.

This points to the psychological or cultural appeal of cosmetic genital surgery among young women and girls, the study’s authors say, which may be influenced by grooming trends that expose the vulva – two-thirds of women in the study had removed their pubic hair – and by widespread advertising of the surgical procedures using before-and-after photos, which about one-third of subjects reported having consulted (BJOG 2011 Aug. 24 [doi:10.1111/j.1471-0528.2011.03088.x]).

"We noticed that more young women were coming in saying, ‘we’re not normal,’ " said Dr. Sarah Creighton, a gynecologist at University College London’s Elizabeth Garrett Anderson Institute of Women’s Health and the corresponding author of the study, in an interview. "And yet there is little information about what is normal."

For their research, Dr. Creighton and colleagues at a London hospital clinic (which performs the surgeries on women whose genitalia are outside normal measures) interviewed women referred to them by primary care physicians. Two-thirds of the women seeking surgery identified themselves as students, only 15% had given birth, and two-thirds reported being single. Most (84%) were white.

The women did not appear to be guided by sexual concerns, as a majority (61%) reported having never been sexually active.

Dr. Creighton and colleagues interviewed the women on their reasons for seeking surgery, and found that most (78%) were motivated by concerns about the appearance of their genitals. Although discomfort, such as that caused by rubbing or chafing, was reported by 57% of them, only 18% said that they thought surgery would help.

The investigators also measured the women’s labia, finding all but three to be within normal published limits, with a mean (SD) of 26.9 (12.8) mm on the right side, and 24.8 (13.1) mm on the left. Surgeries were offered only to those women whose labia were outside that range.

The investigators were surprised, they wrote, to find "that all of the study participants and their referring doctors should have felt that surgery was an appropriate treatment," when the women’s labia were normal. Moreover, 40% of the 30 participants who were denied surgery by the clinic "remained keen to pursue surgery by any other available route."

About 2,000 women now receive the surgeries every year through NHS clinics, a fivefold increase from a decade ago, Dr. Creighton and colleagues noted, with privately performed procedures likely accounting for a far greater number. Yet despite the expanding availability of the procedure, a U.K. law prohibits female genital surgeries for cultural or nontherapeutic reasons, even on adult women.

Thus far, Dr. Creighton said, no lawsuit has challenged the legality of the procedure, which some NHS trusts offer on the grounds of alleviating psychological distress.

"There are no guidelines. The NHS is not publicly discussing it," Dr. Creighton said, adding that professional surgical associations have not issued clear guidelines for treating women seeking labial surgery, leaving clinician discretion as the norm.

"National care standards are urgently needed," Dr. Creighton and colleagues wrote in their analysis. The investigators also urged the publication of data on normal labial measurements "based on a large adult general population sample stratified according to age, ethnicity and parity."

The study was funded by the Elizabeth Garrett Anderson Institute of Women’s Health at University College London. None of its authors declared conflicts of interest.

Women seeking genital surgery to reduce the size of their labia minora do not have large or misshapen labia, and also tend to be relatively young, a small U.K. study has found.

Of the 33 women in the prospective study, published Aug. 24 in BJOG, 30 had labia with dimensions within the normal published limits, yet sought surgery anyway. The women’s average age was 23 years, although a quarter were 16 years or younger, with the youngest being 11 years old.

This points to the psychological or cultural appeal of cosmetic genital surgery among young women and girls, the study’s authors say, which may be influenced by grooming trends that expose the vulva – two-thirds of women in the study had removed their pubic hair – and by widespread advertising of the surgical procedures using before-and-after photos, which about one-third of subjects reported having consulted (BJOG 2011 Aug. 24 [doi:10.1111/j.1471-0528.2011.03088.x]).

"We noticed that more young women were coming in saying, ‘we’re not normal,’ " said Dr. Sarah Creighton, a gynecologist at University College London’s Elizabeth Garrett Anderson Institute of Women’s Health and the corresponding author of the study, in an interview. "And yet there is little information about what is normal."

For their research, Dr. Creighton and colleagues at a London hospital clinic (which performs the surgeries on women whose genitalia are outside normal measures) interviewed women referred to them by primary care physicians. Two-thirds of the women seeking surgery identified themselves as students, only 15% had given birth, and two-thirds reported being single. Most (84%) were white.

The women did not appear to be guided by sexual concerns, as a majority (61%) reported having never been sexually active.

Dr. Creighton and colleagues interviewed the women on their reasons for seeking surgery, and found that most (78%) were motivated by concerns about the appearance of their genitals. Although discomfort, such as that caused by rubbing or chafing, was reported by 57% of them, only 18% said that they thought surgery would help.

The investigators also measured the women’s labia, finding all but three to be within normal published limits, with a mean (SD) of 26.9 (12.8) mm on the right side, and 24.8 (13.1) mm on the left. Surgeries were offered only to those women whose labia were outside that range.

The investigators were surprised, they wrote, to find "that all of the study participants and their referring doctors should have felt that surgery was an appropriate treatment," when the women’s labia were normal. Moreover, 40% of the 30 participants who were denied surgery by the clinic "remained keen to pursue surgery by any other available route."

About 2,000 women now receive the surgeries every year through NHS clinics, a fivefold increase from a decade ago, Dr. Creighton and colleagues noted, with privately performed procedures likely accounting for a far greater number. Yet despite the expanding availability of the procedure, a U.K. law prohibits female genital surgeries for cultural or nontherapeutic reasons, even on adult women.

Thus far, Dr. Creighton said, no lawsuit has challenged the legality of the procedure, which some NHS trusts offer on the grounds of alleviating psychological distress.

"There are no guidelines. The NHS is not publicly discussing it," Dr. Creighton said, adding that professional surgical associations have not issued clear guidelines for treating women seeking labial surgery, leaving clinician discretion as the norm.

"National care standards are urgently needed," Dr. Creighton and colleagues wrote in their analysis. The investigators also urged the publication of data on normal labial measurements "based on a large adult general population sample stratified according to age, ethnicity and parity."

The study was funded by the Elizabeth Garrett Anderson Institute of Women’s Health at University College London. None of its authors declared conflicts of interest.

Women seeking genital surgery to reduce the size of their labia minora do not have large or misshapen labia, and also tend to be relatively young, a small U.K. study has found.

Of the 33 women in the prospective study, published Aug. 24 in BJOG, 30 had labia with dimensions within the normal published limits, yet sought surgery anyway. The women’s average age was 23 years, although a quarter were 16 years or younger, with the youngest being 11 years old.

This points to the psychological or cultural appeal of cosmetic genital surgery among young women and girls, the study’s authors say, which may be influenced by grooming trends that expose the vulva – two-thirds of women in the study had removed their pubic hair – and by widespread advertising of the surgical procedures using before-and-after photos, which about one-third of subjects reported having consulted (BJOG 2011 Aug. 24 [doi:10.1111/j.1471-0528.2011.03088.x]).

"We noticed that more young women were coming in saying, ‘we’re not normal,’ " said Dr. Sarah Creighton, a gynecologist at University College London’s Elizabeth Garrett Anderson Institute of Women’s Health and the corresponding author of the study, in an interview. "And yet there is little information about what is normal."

For their research, Dr. Creighton and colleagues at a London hospital clinic (which performs the surgeries on women whose genitalia are outside normal measures) interviewed women referred to them by primary care physicians. Two-thirds of the women seeking surgery identified themselves as students, only 15% had given birth, and two-thirds reported being single. Most (84%) were white.

The women did not appear to be guided by sexual concerns, as a majority (61%) reported having never been sexually active.

Dr. Creighton and colleagues interviewed the women on their reasons for seeking surgery, and found that most (78%) were motivated by concerns about the appearance of their genitals. Although discomfort, such as that caused by rubbing or chafing, was reported by 57% of them, only 18% said that they thought surgery would help.

The investigators also measured the women’s labia, finding all but three to be within normal published limits, with a mean (SD) of 26.9 (12.8) mm on the right side, and 24.8 (13.1) mm on the left. Surgeries were offered only to those women whose labia were outside that range.

The investigators were surprised, they wrote, to find "that all of the study participants and their referring doctors should have felt that surgery was an appropriate treatment," when the women’s labia were normal. Moreover, 40% of the 30 participants who were denied surgery by the clinic "remained keen to pursue surgery by any other available route."

About 2,000 women now receive the surgeries every year through NHS clinics, a fivefold increase from a decade ago, Dr. Creighton and colleagues noted, with privately performed procedures likely accounting for a far greater number. Yet despite the expanding availability of the procedure, a U.K. law prohibits female genital surgeries for cultural or nontherapeutic reasons, even on adult women.

Thus far, Dr. Creighton said, no lawsuit has challenged the legality of the procedure, which some NHS trusts offer on the grounds of alleviating psychological distress.

"There are no guidelines. The NHS is not publicly discussing it," Dr. Creighton said, adding that professional surgical associations have not issued clear guidelines for treating women seeking labial surgery, leaving clinician discretion as the norm.

"National care standards are urgently needed," Dr. Creighton and colleagues wrote in their analysis. The investigators also urged the publication of data on normal labial measurements "based on a large adult general population sample stratified according to age, ethnicity and parity."

The study was funded by the Elizabeth Garrett Anderson Institute of Women’s Health at University College London. None of its authors declared conflicts of interest.

Borage, a plant with ferny leaves, electric blue flowers, and cucumberlike fruit, is becoming known in the culinary world as a tasty herb and condiment. But research on the medicinal properties of borage is still in the early stages, despite some promising work showing anti-inflammatory and antierythemic properties. The herb is worth investigating, as it may have dermatologic applications.

Borago officinalis is an annual herb native to Syria and now grown throughout the Mediterranean, Middle East, North Africa, Europe, and South America. Derived from the seeds of the plant, borage seed oil is used in medical practice for its anti-inflammatory activity in the treatment of atopic dermatitis, arthritis, and other conditions. In fact, the use of borage oil has demonstrated efficacy as a topical therapeutic approach to childhood eczema in small studies in which, for example, the symptoms of childhood atopic dermatitis were relieved by undershirts coated with borage oil (Eur. J. Dermatol. 2007;17:448-9; J. Dermatol. 2007;34:811-5; J. Fam. Pract. 2009;58:280-1).

Courtesy flickr/anemoneprojectors/creative commons license

Significantly, borage seed oil is also the best plant source of the omega-6 essential fatty acid gamma-linolenic acid (GLA), with GLA accounting for about a quarter of the oil and some extraction processes yielding products with over 50% GLA. Human skin cannot synthesize GLA from the precursor linoleic acid, which is notable because GLA is believed to contribute to skin hydration. As an oral supplement, borage seed oil is believed to be useful in reducing skin inflammation and erythema. As an ingredient in topical applications, it is thought to moisturize and strengthen the skin barrier. This column will discuss recent research on the role of borage seed oil and GLA in modern dermatologic care.

Anti-inflammatory Properties

Some 20 years ago, in response to reports that GLA-containing vegetable oils contributed to reducing the symptoms of inflammatory skin conditions, Miller et al. fed guinea pigs borage oil, containing 25% GLA, or a control diet containing safflower oil (less than 0.5% GLA) for 8 weeks to establish whether GLA could modulate cutaneous eicosanoids. Examination of epidermal samples, including neutral lipids and phospholipids, revealed a significant increase in GLA and dihomo-gamma-linolenic acid (DGLA), its elongase product. Analysis of epidermal eicosanoids showed substantial rises in 15-hydroxy fatty acid (15-OH-20:3n-6) and prostaglandin PGE1, both metabolites of DGLA (and both of which display anti-inflammatory potential), in the borage oil–fed guinea pigs. The authors concluded that increased dietary GLA has the potential to produce local anti-inflammatory metabolites, thus representing a nontoxic approach to treating inflammatory skin disorders (Biochem. Biophys. Res. Commun. 1988;154:967-74).

In a study 3 years later, Miller et al. supplemented the diets of normal guinea pigs with various polyunsaturated fatty acids, ethyl esters of either fish oil (rich in the omega-3 fatty acids eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) or gamma-linolenic acid–rich borage oil, to determine the epidermal effects. The researchers found that guinea pigs that were administered borage oil preferentially incorporated DGLA, the epidermal elongase product of GLA, into epidermal phospholipids. EPA and DHA were also incorporated into epidermal phospholipids in the group that was fed fish oil. The investigators then considered the epidermal levels of the 15-lipoxygenase products and their relative inhibitory strengths to develop a method to quantify the overall potential of the dietary oils to yield local anti-inflammatory results.

Consequently, they noted that fish oil and borage oil leukotriene inhibition potentials greatly surpassed that of controls. The investigators concluded that the reported beneficial effects of fish and borage oils in the treatment of chronic inflammatory skin disorders may be at least partly attributed to the effects on the epidermal 15-lipoxygenase products engendered by the dietary oils (J. Invest. Dermatol. 1991;96:98-103).

Transepidermal Water Loss Impact

In 1993, Tollefson and Frithz studied the significance of transepidermal water loss (TEWL) and stratum corneum water content in disease and recovery in 37 patients with clinically diagnosed infantile seborrheic dermatitis. Within 3-4 weeks of a daily regimen of topically applied borage oil containing 24% GLA, all patients were symptom free. In the assessment of TEWL and stratum corneum water content, 25 healthy, age-matched children served as controls. Although there were no significant differences between the groups in terms of stratum corneum water content, significant pretreatment differences in TEWL were found between patients and controls. There were no significant differences after treatment, however. The investigators concluded that GLA is key to maintaining normal TEWL and as a treatment for infantile seborrheic dermatitis (Acta Derm. Venereol. 1993;73:18-20; Br. J. Dermatol. 1993;129:95).

In 2000, Brosche and Platt assessed the effects of borage oil consumption on various skin parameters in 29 healthy elderly people (mean age, 68.6 years). The subjects received a daily dose of 360- or 720-mg GLA from borage oil in gelatin capsules for 2 months. A statistically significant improvement in cutaneous barrier function was noted, as indicated by a mean decrease of 10.8% in TEWL. Although no significant changes in skin hydration were quantified, 42% of the participants reported dry skin prior to borage oil consumption and only 14% after using the test compound. In addition, pruritus was reported by 34% before treatment and by 0% after treatment. The researchers concluded that consumption of borage oil improved the skin function of their healthy elderly study participants (Arch. Gerontol. Geriatr. 2000;30:139-50).

In 2008, investigators studied the cutaneous effects of various constituents of a fermented dairy product. Specifically, they were interested in the bioavailability in the epidermis of the mixture of borage oil, catechins, vitamin E, and probiotics. After determining bioavailability in plasma samples, the researchers conducted a 24-week skin nutrition study in female volunteers who had dry and sensitive skin. As early as 6 weeks into the study, subjects were found to have improved stratum corneum barrier function, compared with a control product. TEWL relative to the control was also maintained through the length of the study despite seasonal weather changes. The investigators noted that the cutaneous effects of the dairy product yielded greater skin barrier function than any effects yet seen from the individual ingredients (Exp. Dermatol. 2008;17:668-74).

Uses of Borage for Eczema and Skin Reddening

A decade ago, Henz et al. conducted a 24-week, double-blind, multicenter study with 160 adults with stable, moderately severe atopic eczema who were randomized to take daily a 500-mg borage oil capsule or a placebo. The investigators noted that although several clinical symptoms improved in association with the borage oil in comparison to placebo, statistical significance was not achieved in the overall response in the borage oil group. However, significant differences in a subgroup of patients were found that suggested positive effects conferred by borage oil. These patients failed to experience increased erythrocyte DGLA levels, and investigators were not confident regarding the group’s adherence to inclusion criteria and the study protocol. The researchers observed, though, that GLA metabolites increased in the borage oil–treated patients in this group, and serum IgE appeared to be on the wane (Br. J. Dermatol. 1999;140:685-8).

In early 2009, investigators tested the cutaneous effects of flaxseed oil and borage oil supplementation in a 12-week study of two groups of women. Alpha-linolenic and linoleic acids were major constituents in the flaxseed oil doses, and linoleic and gamma-linolenic acids were the primary components in the borage oil supplement. Medium-chain fatty acids made up the placebo that was administered to the control group. Both test groups experienced a decline in skin reddening and blood flow over the study, whereas skin hydration was significantly enhanced. (Hydration was the only parameter affected in the placebo group.)

After 6 weeks of supplementation, a 10% decrease in TEWL was noted in both groups, with an additional reduction after 12 weeks identified in the flaxseed group. Investigators’ assessments indicated that skin roughness and scaling decreased significantly over the study period in both groups, as they concluded that intervention with dietary lipids can influence cutaneous properties (Br. J. Nutr. 2009;101:440-5).

Conclusion

Borage, as the greatest natural source of gamma-linolenic acid (GLA), is a significant plant in dermatology. Mounting evidence suggests that GLA-rich borage seed oil imparts anti-inflammatory activity in the treatment of various medical conditions, including several cutaneous ones. Borage seed oil and GLA have been shown to be effective through oral supplementation and topical administration.

Borage, a plant with ferny leaves, electric blue flowers, and cucumberlike fruit, is becoming known in the culinary world as a tasty herb and condiment. But research on the medicinal properties of borage is still in the early stages, despite some promising work showing anti-inflammatory and antierythemic properties. The herb is worth investigating, as it may have dermatologic applications.

Borago officinalis is an annual herb native to Syria and now grown throughout the Mediterranean, Middle East, North Africa, Europe, and South America. Derived from the seeds of the plant, borage seed oil is used in medical practice for its anti-inflammatory activity in the treatment of atopic dermatitis, arthritis, and other conditions. In fact, the use of borage oil has demonstrated efficacy as a topical therapeutic approach to childhood eczema in small studies in which, for example, the symptoms of childhood atopic dermatitis were relieved by undershirts coated with borage oil (Eur. J. Dermatol. 2007;17:448-9; J. Dermatol. 2007;34:811-5; J. Fam. Pract. 2009;58:280-1).

Courtesy flickr/anemoneprojectors/creative commons license

Significantly, borage seed oil is also the best plant source of the omega-6 essential fatty acid gamma-linolenic acid (GLA), with GLA accounting for about a quarter of the oil and some extraction processes yielding products with over 50% GLA. Human skin cannot synthesize GLA from the precursor linoleic acid, which is notable because GLA is believed to contribute to skin hydration. As an oral supplement, borage seed oil is believed to be useful in reducing skin inflammation and erythema. As an ingredient in topical applications, it is thought to moisturize and strengthen the skin barrier. This column will discuss recent research on the role of borage seed oil and GLA in modern dermatologic care.

Anti-inflammatory Properties

Some 20 years ago, in response to reports that GLA-containing vegetable oils contributed to reducing the symptoms of inflammatory skin conditions, Miller et al. fed guinea pigs borage oil, containing 25% GLA, or a control diet containing safflower oil (less than 0.5% GLA) for 8 weeks to establish whether GLA could modulate cutaneous eicosanoids. Examination of epidermal samples, including neutral lipids and phospholipids, revealed a significant increase in GLA and dihomo-gamma-linolenic acid (DGLA), its elongase product. Analysis of epidermal eicosanoids showed substantial rises in 15-hydroxy fatty acid (15-OH-20:3n-6) and prostaglandin PGE1, both metabolites of DGLA (and both of which display anti-inflammatory potential), in the borage oil–fed guinea pigs. The authors concluded that increased dietary GLA has the potential to produce local anti-inflammatory metabolites, thus representing a nontoxic approach to treating inflammatory skin disorders (Biochem. Biophys. Res. Commun. 1988;154:967-74).

In a study 3 years later, Miller et al. supplemented the diets of normal guinea pigs with various polyunsaturated fatty acids, ethyl esters of either fish oil (rich in the omega-3 fatty acids eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) or gamma-linolenic acid–rich borage oil, to determine the epidermal effects. The researchers found that guinea pigs that were administered borage oil preferentially incorporated DGLA, the epidermal elongase product of GLA, into epidermal phospholipids. EPA and DHA were also incorporated into epidermal phospholipids in the group that was fed fish oil. The investigators then considered the epidermal levels of the 15-lipoxygenase products and their relative inhibitory strengths to develop a method to quantify the overall potential of the dietary oils to yield local anti-inflammatory results.

Consequently, they noted that fish oil and borage oil leukotriene inhibition potentials greatly surpassed that of controls. The investigators concluded that the reported beneficial effects of fish and borage oils in the treatment of chronic inflammatory skin disorders may be at least partly attributed to the effects on the epidermal 15-lipoxygenase products engendered by the dietary oils (J. Invest. Dermatol. 1991;96:98-103).

Transepidermal Water Loss Impact

In 1993, Tollefson and Frithz studied the significance of transepidermal water loss (TEWL) and stratum corneum water content in disease and recovery in 37 patients with clinically diagnosed infantile seborrheic dermatitis. Within 3-4 weeks of a daily regimen of topically applied borage oil containing 24% GLA, all patients were symptom free. In the assessment of TEWL and stratum corneum water content, 25 healthy, age-matched children served as controls. Although there were no significant differences between the groups in terms of stratum corneum water content, significant pretreatment differences in TEWL were found between patients and controls. There were no significant differences after treatment, however. The investigators concluded that GLA is key to maintaining normal TEWL and as a treatment for infantile seborrheic dermatitis (Acta Derm. Venereol. 1993;73:18-20; Br. J. Dermatol. 1993;129:95).

In 2000, Brosche and Platt assessed the effects of borage oil consumption on various skin parameters in 29 healthy elderly people (mean age, 68.6 years). The subjects received a daily dose of 360- or 720-mg GLA from borage oil in gelatin capsules for 2 months. A statistically significant improvement in cutaneous barrier function was noted, as indicated by a mean decrease of 10.8% in TEWL. Although no significant changes in skin hydration were quantified, 42% of the participants reported dry skin prior to borage oil consumption and only 14% after using the test compound. In addition, pruritus was reported by 34% before treatment and by 0% after treatment. The researchers concluded that consumption of borage oil improved the skin function of their healthy elderly study participants (Arch. Gerontol. Geriatr. 2000;30:139-50).

In 2008, investigators studied the cutaneous effects of various constituents of a fermented dairy product. Specifically, they were interested in the bioavailability in the epidermis of the mixture of borage oil, catechins, vitamin E, and probiotics. After determining bioavailability in plasma samples, the researchers conducted a 24-week skin nutrition study in female volunteers who had dry and sensitive skin. As early as 6 weeks into the study, subjects were found to have improved stratum corneum barrier function, compared with a control product. TEWL relative to the control was also maintained through the length of the study despite seasonal weather changes. The investigators noted that the cutaneous effects of the dairy product yielded greater skin barrier function than any effects yet seen from the individual ingredients (Exp. Dermatol. 2008;17:668-74).

Uses of Borage for Eczema and Skin Reddening

A decade ago, Henz et al. conducted a 24-week, double-blind, multicenter study with 160 adults with stable, moderately severe atopic eczema who were randomized to take daily a 500-mg borage oil capsule or a placebo. The investigators noted that although several clinical symptoms improved in association with the borage oil in comparison to placebo, statistical significance was not achieved in the overall response in the borage oil group. However, significant differences in a subgroup of patients were found that suggested positive effects conferred by borage oil. These patients failed to experience increased erythrocyte DGLA levels, and investigators were not confident regarding the group’s adherence to inclusion criteria and the study protocol. The researchers observed, though, that GLA metabolites increased in the borage oil–treated patients in this group, and serum IgE appeared to be on the wane (Br. J. Dermatol. 1999;140:685-8).

In early 2009, investigators tested the cutaneous effects of flaxseed oil and borage oil supplementation in a 12-week study of two groups of women. Alpha-linolenic and linoleic acids were major constituents in the flaxseed oil doses, and linoleic and gamma-linolenic acids were the primary components in the borage oil supplement. Medium-chain fatty acids made up the placebo that was administered to the control group. Both test groups experienced a decline in skin reddening and blood flow over the study, whereas skin hydration was significantly enhanced. (Hydration was the only parameter affected in the placebo group.)

After 6 weeks of supplementation, a 10% decrease in TEWL was noted in both groups, with an additional reduction after 12 weeks identified in the flaxseed group. Investigators’ assessments indicated that skin roughness and scaling decreased significantly over the study period in both groups, as they concluded that intervention with dietary lipids can influence cutaneous properties (Br. J. Nutr. 2009;101:440-5).

Conclusion

Borage, as the greatest natural source of gamma-linolenic acid (GLA), is a significant plant in dermatology. Mounting evidence suggests that GLA-rich borage seed oil imparts anti-inflammatory activity in the treatment of various medical conditions, including several cutaneous ones. Borage seed oil and GLA have been shown to be effective through oral supplementation and topical administration.

Borage, a plant with ferny leaves, electric blue flowers, and cucumberlike fruit, is becoming known in the culinary world as a tasty herb and condiment. But research on the medicinal properties of borage is still in the early stages, despite some promising work showing anti-inflammatory and antierythemic properties. The herb is worth investigating, as it may have dermatologic applications.

Borago officinalis is an annual herb native to Syria and now grown throughout the Mediterranean, Middle East, North Africa, Europe, and South America. Derived from the seeds of the plant, borage seed oil is used in medical practice for its anti-inflammatory activity in the treatment of atopic dermatitis, arthritis, and other conditions. In fact, the use of borage oil has demonstrated efficacy as a topical therapeutic approach to childhood eczema in small studies in which, for example, the symptoms of childhood atopic dermatitis were relieved by undershirts coated with borage oil (Eur. J. Dermatol. 2007;17:448-9; J. Dermatol. 2007;34:811-5; J. Fam. Pract. 2009;58:280-1).

Courtesy flickr/anemoneprojectors/creative commons license

Significantly, borage seed oil is also the best plant source of the omega-6 essential fatty acid gamma-linolenic acid (GLA), with GLA accounting for about a quarter of the oil and some extraction processes yielding products with over 50% GLA. Human skin cannot synthesize GLA from the precursor linoleic acid, which is notable because GLA is believed to contribute to skin hydration. As an oral supplement, borage seed oil is believed to be useful in reducing skin inflammation and erythema. As an ingredient in topical applications, it is thought to moisturize and strengthen the skin barrier. This column will discuss recent research on the role of borage seed oil and GLA in modern dermatologic care.

Anti-inflammatory Properties

Some 20 years ago, in response to reports that GLA-containing vegetable oils contributed to reducing the symptoms of inflammatory skin conditions, Miller et al. fed guinea pigs borage oil, containing 25% GLA, or a control diet containing safflower oil (less than 0.5% GLA) for 8 weeks to establish whether GLA could modulate cutaneous eicosanoids. Examination of epidermal samples, including neutral lipids and phospholipids, revealed a significant increase in GLA and dihomo-gamma-linolenic acid (DGLA), its elongase product. Analysis of epidermal eicosanoids showed substantial rises in 15-hydroxy fatty acid (15-OH-20:3n-6) and prostaglandin PGE1, both metabolites of DGLA (and both of which display anti-inflammatory potential), in the borage oil–fed guinea pigs. The authors concluded that increased dietary GLA has the potential to produce local anti-inflammatory metabolites, thus representing a nontoxic approach to treating inflammatory skin disorders (Biochem. Biophys. Res. Commun. 1988;154:967-74).

In a study 3 years later, Miller et al. supplemented the diets of normal guinea pigs with various polyunsaturated fatty acids, ethyl esters of either fish oil (rich in the omega-3 fatty acids eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) or gamma-linolenic acid–rich borage oil, to determine the epidermal effects. The researchers found that guinea pigs that were administered borage oil preferentially incorporated DGLA, the epidermal elongase product of GLA, into epidermal phospholipids. EPA and DHA were also incorporated into epidermal phospholipids in the group that was fed fish oil. The investigators then considered the epidermal levels of the 15-lipoxygenase products and their relative inhibitory strengths to develop a method to quantify the overall potential of the dietary oils to yield local anti-inflammatory results.

Consequently, they noted that fish oil and borage oil leukotriene inhibition potentials greatly surpassed that of controls. The investigators concluded that the reported beneficial effects of fish and borage oils in the treatment of chronic inflammatory skin disorders may be at least partly attributed to the effects on the epidermal 15-lipoxygenase products engendered by the dietary oils (J. Invest. Dermatol. 1991;96:98-103).

Transepidermal Water Loss Impact

In 1993, Tollefson and Frithz studied the significance of transepidermal water loss (TEWL) and stratum corneum water content in disease and recovery in 37 patients with clinically diagnosed infantile seborrheic dermatitis. Within 3-4 weeks of a daily regimen of topically applied borage oil containing 24% GLA, all patients were symptom free. In the assessment of TEWL and stratum corneum water content, 25 healthy, age-matched children served as controls. Although there were no significant differences between the groups in terms of stratum corneum water content, significant pretreatment differences in TEWL were found between patients and controls. There were no significant differences after treatment, however. The investigators concluded that GLA is key to maintaining normal TEWL and as a treatment for infantile seborrheic dermatitis (Acta Derm. Venereol. 1993;73:18-20; Br. J. Dermatol. 1993;129:95).

In 2000, Brosche and Platt assessed the effects of borage oil consumption on various skin parameters in 29 healthy elderly people (mean age, 68.6 years). The subjects received a daily dose of 360- or 720-mg GLA from borage oil in gelatin capsules for 2 months. A statistically significant improvement in cutaneous barrier function was noted, as indicated by a mean decrease of 10.8% in TEWL. Although no significant changes in skin hydration were quantified, 42% of the participants reported dry skin prior to borage oil consumption and only 14% after using the test compound. In addition, pruritus was reported by 34% before treatment and by 0% after treatment. The researchers concluded that consumption of borage oil improved the skin function of their healthy elderly study participants (Arch. Gerontol. Geriatr. 2000;30:139-50).

In 2008, investigators studied the cutaneous effects of various constituents of a fermented dairy product. Specifically, they were interested in the bioavailability in the epidermis of the mixture of borage oil, catechins, vitamin E, and probiotics. After determining bioavailability in plasma samples, the researchers conducted a 24-week skin nutrition study in female volunteers who had dry and sensitive skin. As early as 6 weeks into the study, subjects were found to have improved stratum corneum barrier function, compared with a control product. TEWL relative to the control was also maintained through the length of the study despite seasonal weather changes. The investigators noted that the cutaneous effects of the dairy product yielded greater skin barrier function than any effects yet seen from the individual ingredients (Exp. Dermatol. 2008;17:668-74).

Uses of Borage for Eczema and Skin Reddening

A decade ago, Henz et al. conducted a 24-week, double-blind, multicenter study with 160 adults with stable, moderately severe atopic eczema who were randomized to take daily a 500-mg borage oil capsule or a placebo. The investigators noted that although several clinical symptoms improved in association with the borage oil in comparison to placebo, statistical significance was not achieved in the overall response in the borage oil group. However, significant differences in a subgroup of patients were found that suggested positive effects conferred by borage oil. These patients failed to experience increased erythrocyte DGLA levels, and investigators were not confident regarding the group’s adherence to inclusion criteria and the study protocol. The researchers observed, though, that GLA metabolites increased in the borage oil–treated patients in this group, and serum IgE appeared to be on the wane (Br. J. Dermatol. 1999;140:685-8).

In early 2009, investigators tested the cutaneous effects of flaxseed oil and borage oil supplementation in a 12-week study of two groups of women. Alpha-linolenic and linoleic acids were major constituents in the flaxseed oil doses, and linoleic and gamma-linolenic acids were the primary components in the borage oil supplement. Medium-chain fatty acids made up the placebo that was administered to the control group. Both test groups experienced a decline in skin reddening and blood flow over the study, whereas skin hydration was significantly enhanced. (Hydration was the only parameter affected in the placebo group.)

After 6 weeks of supplementation, a 10% decrease in TEWL was noted in both groups, with an additional reduction after 12 weeks identified in the flaxseed group. Investigators’ assessments indicated that skin roughness and scaling decreased significantly over the study period in both groups, as they concluded that intervention with dietary lipids can influence cutaneous properties (Br. J. Nutr. 2009;101:440-5).

Conclusion

Borage, as the greatest natural source of gamma-linolenic acid (GLA), is a significant plant in dermatology. Mounting evidence suggests that GLA-rich borage seed oil imparts anti-inflammatory activity in the treatment of various medical conditions, including several cutaneous ones. Borage seed oil and GLA have been shown to be effective through oral supplementation and topical administration.

The growing diversity of the U.S. population has highlighted the importance of being able to properly treat skin of color patients.

The topic was the focus of a presentation by Dr. Wendy E. Roberts during the American Academy of Dermatology's Summer Academy Meeting in New York. She is in private practice in Rancho Mirage, Calif.

When it comes to treating skin of color, dermatologists should keep three main points in mind, said Dr. Roberts: recognition of the skin disease, treatment, and procedural safely. (Dr. Roberts explains each point in the video below.)

For instance, acne, which is the most common skin condition, can affect dark skin differently than in patients with light skin. Postinflammatory hyperpigmentation (PIH) is one of the unique characteristics of acne expression in ethnic skin.

Patients may not visit the dermatologist because of the primary lesions such as papules and postules, said Dr. Roberts. Rather, they may come in because of the brown spot on their skin.

Based on the patients' skin type and severity of acne, dermatologists have access to several treatment options for PIH, which include the gold standard hydroquinone and retinoids that help lighten the affected areas. Other options include chemical peels, microdermabrasion, and fractional lasers.

A 2010 review of acne in skin of color patients showed that clinical features such as PIH and potential irritation, "should influence the choice of anti-acne agents used when designing a treatment regimen" (J. Clin. Aesthet. Dematol. 2010;3:24-38).

The growing diversity of the U.S. population has highlighted the importance of being able to properly treat skin of color patients.

The topic was the focus of a presentation by Dr. Wendy E. Roberts during the American Academy of Dermatology's Summer Academy Meeting in New York. She is in private practice in Rancho Mirage, Calif.

When it comes to treating skin of color, dermatologists should keep three main points in mind, said Dr. Roberts: recognition of the skin disease, treatment, and procedural safely. (Dr. Roberts explains each point in the video below.)

For instance, acne, which is the most common skin condition, can affect dark skin differently than in patients with light skin. Postinflammatory hyperpigmentation (PIH) is one of the unique characteristics of acne expression in ethnic skin.

Patients may not visit the dermatologist because of the primary lesions such as papules and postules, said Dr. Roberts. Rather, they may come in because of the brown spot on their skin.

Based on the patients' skin type and severity of acne, dermatologists have access to several treatment options for PIH, which include the gold standard hydroquinone and retinoids that help lighten the affected areas. Other options include chemical peels, microdermabrasion, and fractional lasers.

A 2010 review of acne in skin of color patients showed that clinical features such as PIH and potential irritation, "should influence the choice of anti-acne agents used when designing a treatment regimen" (J. Clin. Aesthet. Dematol. 2010;3:24-38).

The growing diversity of the U.S. population has highlighted the importance of being able to properly treat skin of color patients.

The topic was the focus of a presentation by Dr. Wendy E. Roberts during the American Academy of Dermatology's Summer Academy Meeting in New York. She is in private practice in Rancho Mirage, Calif.

When it comes to treating skin of color, dermatologists should keep three main points in mind, said Dr. Roberts: recognition of the skin disease, treatment, and procedural safely. (Dr. Roberts explains each point in the video below.)

For instance, acne, which is the most common skin condition, can affect dark skin differently than in patients with light skin. Postinflammatory hyperpigmentation (PIH) is one of the unique characteristics of acne expression in ethnic skin.

Patients may not visit the dermatologist because of the primary lesions such as papules and postules, said Dr. Roberts. Rather, they may come in because of the brown spot on their skin.

Based on the patients' skin type and severity of acne, dermatologists have access to several treatment options for PIH, which include the gold standard hydroquinone and retinoids that help lighten the affected areas. Other options include chemical peels, microdermabrasion, and fractional lasers.

A 2010 review of acne in skin of color patients showed that clinical features such as PIH and potential irritation, "should influence the choice of anti-acne agents used when designing a treatment regimen" (J. Clin. Aesthet. Dematol. 2010;3:24-38).

NEW YORK – Zinc oxide and titanium dioxide have a long history of use – from paint pigment to diaper rash remedy. They’ve even made a beach-side fashion statement among sun seekers who protect their ears and nose with a thick, white slathering of the light-reflecting mineral cream.

But these inert particles may someday form the basis of the "perfect sunscreen," Dr. Zoe Draelos said at the American Academy of Dermatology’s Summer Academy meeting. Such a compound would completely protect against both ultraviolet B and the more-damaging ultraviolet A while being completely invisible on skin types I-VI.

©Corbis/Fotolia.com

Nanoparticles are highly refined substances with a particle size of 15-100 nm. Theoretically, Dr. Draelos said, nanoparticulate zinc oxide and titanium dioxide could be dispersed in a comfortable vehicle that would be invisible even on dark skin, easy to apply, last a long time, and provide full-spectrum protection – all attributes that could increase user compliance and, therefore, overall skin safety.

Unfortunately, like most things that seem too good to be true, nanoparticles lug around some potentially serious baggage, said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C.

"We already know that some nanoparticles cause health risks," she said. "The smog that we breathed in on the way to this meeting contained carbon and other nanoparticles, which are so small that they escape phagocytosis, making it virtually impossible for the body to ever remove them."

Prolonged exposure to inhaled nanoparticles can contribute to lung disease, and there is even preliminary research that smog and some nanoparticles may even impact cardiovascular function.

"Because we already know some things about the potential harm of inhaled nanoparticles, it’s very important that any topical products don’t contain nanoparticles that could be absorbed into the skin," said Dr. Draelos, who is also vice president-elect of the American Academy of Dermatology.

To address the issue, the Food and Drug Administration established a nanotechnology task force in 2007, she said. "But no one has heard from them since." Other groups have cited environmental concerns, pushing the issue to the forefront. But scientific literature about skin absorption has come to conflicting results, some of which may not be applicable to humans.

Risks Associated With Nanoparticles

A 2009 study suggested that titanium dioxide nanoparticles, applied topically to pigs’ ears and to hairless mice, not only penetrated the stratum corneum but later showed up in other organs, including the liver and the brain. The study "indicates that nano-sized titanium dioxide may pose a health risk to humans after dermal exposure over a relative long time period" (Toxicol. Lett. 2009;191:1-8).

But a review published the same year found conflicting evidence (Dermatoendocrinol. 2009;1:197-206). The review examined the absorption of various nanoparticle types, including titanium dioxide and zinc oxide. Citing nine studies on humans, pigs, and mice, the authors concluded that the minerals in sizes of 10-100 nm did not penetrate the human stratum corneum beyond five layers, although they could be seen in the openings of the hair follicles.

Any nanoparticle smaller than 13 nm could potentially penetrate the stratum corneum, Dr. Draelos said, but anything larger would stay on the surface.

"The follicular infundibulum is about 170 micrometers, so nanoparticles can get in there but, as sebum is produced, the particles are washed out onto the skin’s surface. If you had a nanoparticle that was really soluble, it could dissolve into the sebum, but nanoparticles made of these metal oxides don’t dissolve."

Applying a nanoparticle sunscreen to damaged skin could potentially increase the likelihood of absorption, and no one is quite sure what would happen when such a compound concentrates in the body’s creases and folds. Would the additional pressure on the inside of the elbow, for example, facilitate absorption? "No one really knows," she said.

For a sunscreen to remain invisible on all skin types, the nanoparticles would have to be no larger than 10 nm, "putting us right back where we started. So it’s going to be difficult to make an effective nanoparticle sunscreen that will be invisible on all skin types," she added.

To further complicate matters, nanoparticles themselves can be damaging. "When a photon of ultraviolet B radiation strikes a nanoparticle, the particle undergoes photocatalysis, which generates secondary free radicals," said Dr. Draelos. Researchers are trying to tackle this problem with polyester or nylon coatings that block the process.

Although research continues, no nanoparticle sunscreens are available in the United States. Two can be found in Europe. "One uses a 15% concentration of 50-nm zinc oxide and the other, a 5% concentration of 30-nm titanium dioxide," she noted

The Swedish government, however, has blocked 10 companies from marketing such sunscreens because of possible toxicity to aquatic flora, said Dr. Draelos. "These compounds can be toxic to organisms at the bottom of the food chain, including photo- and phytoplankton. The European Union countries have also said that labels must state whether the product contains nanoparticles."

The scientific jury is still out on how to make cosmetically acceptable sunscreens that offer optimal UVA protection while being physically and environmentally safe, Dr. Draelos said. "But we can’t ignore the opportunities they create for novel formulations."

Dr. Draelos disclosed financial relationships with numerous pharmaceutical companies.

NEW YORK – Zinc oxide and titanium dioxide have a long history of use – from paint pigment to diaper rash remedy. They’ve even made a beach-side fashion statement among sun seekers who protect their ears and nose with a thick, white slathering of the light-reflecting mineral cream.

But these inert particles may someday form the basis of the "perfect sunscreen," Dr. Zoe Draelos said at the American Academy of Dermatology’s Summer Academy meeting. Such a compound would completely protect against both ultraviolet B and the more-damaging ultraviolet A while being completely invisible on skin types I-VI.

©Corbis/Fotolia.com

Nanoparticles are highly refined substances with a particle size of 15-100 nm. Theoretically, Dr. Draelos said, nanoparticulate zinc oxide and titanium dioxide could be dispersed in a comfortable vehicle that would be invisible even on dark skin, easy to apply, last a long time, and provide full-spectrum protection – all attributes that could increase user compliance and, therefore, overall skin safety.

Unfortunately, like most things that seem too good to be true, nanoparticles lug around some potentially serious baggage, said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C.

"We already know that some nanoparticles cause health risks," she said. "The smog that we breathed in on the way to this meeting contained carbon and other nanoparticles, which are so small that they escape phagocytosis, making it virtually impossible for the body to ever remove them."

Prolonged exposure to inhaled nanoparticles can contribute to lung disease, and there is even preliminary research that smog and some nanoparticles may even impact cardiovascular function.

"Because we already know some things about the potential harm of inhaled nanoparticles, it’s very important that any topical products don’t contain nanoparticles that could be absorbed into the skin," said Dr. Draelos, who is also vice president-elect of the American Academy of Dermatology.

To address the issue, the Food and Drug Administration established a nanotechnology task force in 2007, she said. "But no one has heard from them since." Other groups have cited environmental concerns, pushing the issue to the forefront. But scientific literature about skin absorption has come to conflicting results, some of which may not be applicable to humans.

Risks Associated With Nanoparticles

A 2009 study suggested that titanium dioxide nanoparticles, applied topically to pigs’ ears and to hairless mice, not only penetrated the stratum corneum but later showed up in other organs, including the liver and the brain. The study "indicates that nano-sized titanium dioxide may pose a health risk to humans after dermal exposure over a relative long time period" (Toxicol. Lett. 2009;191:1-8).

But a review published the same year found conflicting evidence (Dermatoendocrinol. 2009;1:197-206). The review examined the absorption of various nanoparticle types, including titanium dioxide and zinc oxide. Citing nine studies on humans, pigs, and mice, the authors concluded that the minerals in sizes of 10-100 nm did not penetrate the human stratum corneum beyond five layers, although they could be seen in the openings of the hair follicles.

Any nanoparticle smaller than 13 nm could potentially penetrate the stratum corneum, Dr. Draelos said, but anything larger would stay on the surface.

"The follicular infundibulum is about 170 micrometers, so nanoparticles can get in there but, as sebum is produced, the particles are washed out onto the skin’s surface. If you had a nanoparticle that was really soluble, it could dissolve into the sebum, but nanoparticles made of these metal oxides don’t dissolve."

Applying a nanoparticle sunscreen to damaged skin could potentially increase the likelihood of absorption, and no one is quite sure what would happen when such a compound concentrates in the body’s creases and folds. Would the additional pressure on the inside of the elbow, for example, facilitate absorption? "No one really knows," she said.

For a sunscreen to remain invisible on all skin types, the nanoparticles would have to be no larger than 10 nm, "putting us right back where we started. So it’s going to be difficult to make an effective nanoparticle sunscreen that will be invisible on all skin types," she added.

To further complicate matters, nanoparticles themselves can be damaging. "When a photon of ultraviolet B radiation strikes a nanoparticle, the particle undergoes photocatalysis, which generates secondary free radicals," said Dr. Draelos. Researchers are trying to tackle this problem with polyester or nylon coatings that block the process.

Although research continues, no nanoparticle sunscreens are available in the United States. Two can be found in Europe. "One uses a 15% concentration of 50-nm zinc oxide and the other, a 5% concentration of 30-nm titanium dioxide," she noted

The Swedish government, however, has blocked 10 companies from marketing such sunscreens because of possible toxicity to aquatic flora, said Dr. Draelos. "These compounds can be toxic to organisms at the bottom of the food chain, including photo- and phytoplankton. The European Union countries have also said that labels must state whether the product contains nanoparticles."

The scientific jury is still out on how to make cosmetically acceptable sunscreens that offer optimal UVA protection while being physically and environmentally safe, Dr. Draelos said. "But we can’t ignore the opportunities they create for novel formulations."

Dr. Draelos disclosed financial relationships with numerous pharmaceutical companies.

NEW YORK – Zinc oxide and titanium dioxide have a long history of use – from paint pigment to diaper rash remedy. They’ve even made a beach-side fashion statement among sun seekers who protect their ears and nose with a thick, white slathering of the light-reflecting mineral cream.

But these inert particles may someday form the basis of the "perfect sunscreen," Dr. Zoe Draelos said at the American Academy of Dermatology’s Summer Academy meeting. Such a compound would completely protect against both ultraviolet B and the more-damaging ultraviolet A while being completely invisible on skin types I-VI.

©Corbis/Fotolia.com

Nanoparticles are highly refined substances with a particle size of 15-100 nm. Theoretically, Dr. Draelos said, nanoparticulate zinc oxide and titanium dioxide could be dispersed in a comfortable vehicle that would be invisible even on dark skin, easy to apply, last a long time, and provide full-spectrum protection – all attributes that could increase user compliance and, therefore, overall skin safety.

Unfortunately, like most things that seem too good to be true, nanoparticles lug around some potentially serious baggage, said Dr. Draelos, a clinical dermatologist and researcher in High Point, N.C.

"We already know that some nanoparticles cause health risks," she said. "The smog that we breathed in on the way to this meeting contained carbon and other nanoparticles, which are so small that they escape phagocytosis, making it virtually impossible for the body to ever remove them."

Prolonged exposure to inhaled nanoparticles can contribute to lung disease, and there is even preliminary research that smog and some nanoparticles may even impact cardiovascular function.

"Because we already know some things about the potential harm of inhaled nanoparticles, it’s very important that any topical products don’t contain nanoparticles that could be absorbed into the skin," said Dr. Draelos, who is also vice president-elect of the American Academy of Dermatology.

To address the issue, the Food and Drug Administration established a nanotechnology task force in 2007, she said. "But no one has heard from them since." Other groups have cited environmental concerns, pushing the issue to the forefront. But scientific literature about skin absorption has come to conflicting results, some of which may not be applicable to humans.

Risks Associated With Nanoparticles

A 2009 study suggested that titanium dioxide nanoparticles, applied topically to pigs’ ears and to hairless mice, not only penetrated the stratum corneum but later showed up in other organs, including the liver and the brain. The study "indicates that nano-sized titanium dioxide may pose a health risk to humans after dermal exposure over a relative long time period" (Toxicol. Lett. 2009;191:1-8).

But a review published the same year found conflicting evidence (Dermatoendocrinol. 2009;1:197-206). The review examined the absorption of various nanoparticle types, including titanium dioxide and zinc oxide. Citing nine studies on humans, pigs, and mice, the authors concluded that the minerals in sizes of 10-100 nm did not penetrate the human stratum corneum beyond five layers, although they could be seen in the openings of the hair follicles.

Any nanoparticle smaller than 13 nm could potentially penetrate the stratum corneum, Dr. Draelos said, but anything larger would stay on the surface.

"The follicular infundibulum is about 170 micrometers, so nanoparticles can get in there but, as sebum is produced, the particles are washed out onto the skin’s surface. If you had a nanoparticle that was really soluble, it could dissolve into the sebum, but nanoparticles made of these metal oxides don’t dissolve."

Applying a nanoparticle sunscreen to damaged skin could potentially increase the likelihood of absorption, and no one is quite sure what would happen when such a compound concentrates in the body’s creases and folds. Would the additional pressure on the inside of the elbow, for example, facilitate absorption? "No one really knows," she said.

For a sunscreen to remain invisible on all skin types, the nanoparticles would have to be no larger than 10 nm, "putting us right back where we started. So it’s going to be difficult to make an effective nanoparticle sunscreen that will be invisible on all skin types," she added.

To further complicate matters, nanoparticles themselves can be damaging. "When a photon of ultraviolet B radiation strikes a nanoparticle, the particle undergoes photocatalysis, which generates secondary free radicals," said Dr. Draelos. Researchers are trying to tackle this problem with polyester or nylon coatings that block the process.

Although research continues, no nanoparticle sunscreens are available in the United States. Two can be found in Europe. "One uses a 15% concentration of 50-nm zinc oxide and the other, a 5% concentration of 30-nm titanium dioxide," she noted

The Swedish government, however, has blocked 10 companies from marketing such sunscreens because of possible toxicity to aquatic flora, said Dr. Draelos. "These compounds can be toxic to organisms at the bottom of the food chain, including photo- and phytoplankton. The European Union countries have also said that labels must state whether the product contains nanoparticles."

The scientific jury is still out on how to make cosmetically acceptable sunscreens that offer optimal UVA protection while being physically and environmentally safe, Dr. Draelos said. "But we can’t ignore the opportunities they create for novel formulations."

Dr. Draelos disclosed financial relationships with numerous pharmaceutical companies.

In this month's Skinny podcast, we talk with dermatologist and AIDS expert Dr. Marcus Conant on why he believes universal HIV screening is the only way to curb the AIDS epidemic.

Also, Dr. Robert Weiss discusses the new FDA approved filler, Laviv, which uses a patient's own fibroblasts to treat wrinkles.

President of the American College of Mohs Surgery, Dr. Brett Coldiron, gives us his dire predictions about Medicare payments.

In this month's Cosmetic Counter segment, Dr. Lily Talakoub talks about a new rival to Botox and Dysport, which could hit the market next year.

And finally, Dr. Alan Rockoff says it's never too late for a little romance, even if it does involve denture cream.

In this month's Skinny podcast, we talk with dermatologist and AIDS expert Dr. Marcus Conant on why he believes universal HIV screening is the only way to curb the AIDS epidemic.

Also, Dr. Robert Weiss discusses the new FDA approved filler, Laviv, which uses a patient's own fibroblasts to treat wrinkles.

President of the American College of Mohs Surgery, Dr. Brett Coldiron, gives us his dire predictions about Medicare payments.

In this month's Cosmetic Counter segment, Dr. Lily Talakoub talks about a new rival to Botox and Dysport, which could hit the market next year.

And finally, Dr. Alan Rockoff says it's never too late for a little romance, even if it does involve denture cream.

In this month's Skinny podcast, we talk with dermatologist and AIDS expert Dr. Marcus Conant on why he believes universal HIV screening is the only way to curb the AIDS epidemic.

Also, Dr. Robert Weiss discusses the new FDA approved filler, Laviv, which uses a patient's own fibroblasts to treat wrinkles.

President of the American College of Mohs Surgery, Dr. Brett Coldiron, gives us his dire predictions about Medicare payments.

In this month's Cosmetic Counter segment, Dr. Lily Talakoub talks about a new rival to Botox and Dysport, which could hit the market next year.

And finally, Dr. Alan Rockoff says it's never too late for a little romance, even if it does involve denture cream.

Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

BOCA RATON, FLA. – Experience with various lasers for the treatment and prophylaxis of nonmelanoma skin cancers is increasing, and the outcomes are promising.

One setting where lasers have particular potential is in patients with multiple basal cell carcinomas, Dr. Keyvan Nouri said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

BCCs tend to have telangiectasias, and by specifically targeting the tumor vasculature, the BCC burden can be decreased or eliminated by laser treatment with little damage to surrounding skin. An ablative approach can also eliminate premalignant cells, said Dr. Nouri, professor of dermatology and otolaryngology and director of Mohs, dermatologic, and laser surgery at the University of Miami.

Studies using this approach have been conducted over the past several years using CO₂, Er:YAG, pulsed-dye, and alexandrite lasers.

The 10,600-nm CO₂ laser achieves a depth of 15-200 mcm in a single pass, which is adequate for coagulating the epidermis and superficial dermis, and for eliminating squamous cells at risk for evolution to actinic keratosis or squamous cell carcinoma. It also is partially effective for eliminating cells en route to basal cell carcinoma, he said, noting that deeper treatment can be achieved with multiple passes or protocol modifications.

In one study using this CO₂ laser, 14 patients with diffuse facial AKs underwent resurfacing and experienced significant long-term reduction in AK burden (Dermatol. Surg. 1997;23:885-9). In another report of two patients with a history of multiple nonmelanoma skin cancer who were treated with two-pass CO₂ resurfacing, no new lesions developed in the treated area at 33 and 52 months (Dermatol. Surg. 1999;25:513-16).

In a randomized controlled study of 34 patients, no differences in outcomes were seen at 5 years regardless of whether patients were treated with the CO₂ laser, a 30% trichloroacetic acid peel, or 5% fluorouracil cream twice daily for 3 weeks. All of the treatments reduced AK counts by 83%-92%, and reduced the incidence of nonmelanoma skin cancers, compared with control groups (Dermatol. Surg. 1999;25:729-32), Dr. Nouri said.

In three of his patients with basal cell nevus syndrome, the Ultrapulse CO₂ laser also proved effective for treatment. Postoperative Mohs micrographic surgical sections verified complete histologic clearance, and the patients had minimal scarring at follow-up (Dermatol. Surg. 2002;28:287-90).

A high-energy pulsed CO₂ laser has also been used to treat a squamous cell carcinoma in situ on the nose with one pass (at 250 mJ, 8 W). In that case, no recurrence had occurred at 5 months’ follow-up, and the cosmetic result was excellent, Dr. Nouri said.

In a series of patients with nodular and superficial BCCs, a combination of curettage and one or two passes with the high-energy pulsed CO₂ laser was also effective, with no histologic evidence or residual tumor and no known recurrences.

In another study, the pulsed CO₂ laser was effective for treating 30 neoplasms, including 17 BCCs and 13 SCCs (Arch. Dermatol. 1998;134:1247-52). Two or three passes were used (at 500 mJ and 2-4 W). Treatment with a 4-mm margin and three passes is recommended for complete vaporization of neoplasms using this laser, Dr. Nouri said. Also, one SCC in situ in that study was incompletely ablated after three passes, so this modality alone is not recommended for thick or keratotic lesions, he said.

More recently, fractional laser resurfacing and pulsed-dye laser treatment have also shown promise for nonmelanoma skin cancers. In a pilot study of 28 patients with mild to moderate actinic damage who were treated with a fractional Er:YAG laser (2,940 nm) with one to four treatments at 4-week intervals, 75% had excellent results and the other 25% had good results. The effects were maintained at up to 9 months (Dermatol. Surg. 2008;34:1048-53).

And the 595-nm pulsed-dye laser has been used successfully to target tumor vasculature in glottal dysplasia and SCCs. Depending on fluence and spot size, the 595-nm pulsed-dye laser can penetrate skin to thicknesses ranging from 0.75 to 1.25 mm, which encompasses most BCCs, Dr. Nouri said.

In one study, a single treatment on seven BCCs resulted in histologic clearance of only one tumor (Lasers Med. Sci. 2003;18:125-6), but in two other studies of patients with superficial BCCs, this laser was associated with no clinical recurrences at a minimum follow-up of 1 year in 16 of 20 BCCs (Lasers Med. Sci. 2005;20:147-8; Dermatol. Ther. 2008; 21:402-5).

In another study, 20 BCCs treated with four 595-nm pulsed-dye laser treatments at 2-week intervals showed that nearly all BCCs less than 1.5 cm responded completely, compared with about 17% of controls. Larger BCCs had a complete response rate of 25% vs. 0% in controls.

Tumors with an incomplete response showed a significant reduction in tumor burden following treatment, with residual histologic tumor burden ranging from less than 1% to 29% of the original clinical tumor diameter, compared with 13%-68% residual tumor burden for the corresponding controls.

The investigators took the study one step further, treating 14 patients with a total of 20 BCCs on the trunk or extremities with four treatments at 3- to 4-week intervals; 19 of 20 BCCs had a complete clinical response, regardless of size and histological subtype (Lasers Surg. Med. 2009; 41:417-22). The investigators concluded that the 595-nm pulsed-dye laser is a "novel, quick, and relatively nonpainful treatment" for BCCs when used in the appropriate clinical setting, Dr. Nouri said.

As for the long-pulse alexandrite laser, it is selective like the pulsed-dye laser, but has deeper penetration, and may be helpful in significantly reducing tumor burden with a single treatment, he said.

In 15 of 18 patients with basal cell nevus syndrome who were treated in one study, a complete clinical response was seen at follow-ups of 2 and 7 months (Lasers Surg. Med. 2010;42:68-71).

No particular laser has emerged as the ideal tool for the treatment or prevention of skin cancer, but work is ongoing. More research is needed to confirm the observations made thus far, as well as to optimize treatment parameters, but the findings to date are encouraging, Dr. Nouri said, noting that he is confident that laser and light sources will eventually be used more for both medical and oncologic purposes.

Dr. Nouri disclosed that he has received grants or research support from Aesthera, CureLight, and Omnilux.

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – To granulate or not to granulate? That’s the question clinicians may consider after performing dermatologic surgery.

The best sites for granulation are concavities of the temple, ear, eye, and nose, Dr. Malcolm S. Ke said at a meeting on superficial anatomy and cutaneous surgery. "Sometimes superficial convexities also do quite well, such as the nose, mucosal lip, ear, and scalp," he added. "Deeper convexities are less predictable."

Benefits of granulation include easy monitoring and a low infection rate. "There is no hematoma and no suture reactions," said Dr. Ke of the division of dermatology at the University of California, Los Angeles. "It’s one less procedure the patient has to tolerate, it is often less painful for the patient, and it can provide good cosmesis."

Drawbacks include the potential for a long healing time and the fact that wound care is patient dependent. "They have to take care of it every single day, and there is sometimes a less predictable outcome," Dr. Ke said.

Three main agents for preoperative wound care include alcohol 70%, lodophors, and chlorhexidine, "which is my favorite," he said. "It is bactericidal and antipseudomonal. It persists on the skin and is not absorbed, but it is not good for open wounds or around eyes."

Postoperatively, saline works well for keeping wounds clean. "A patient favorite is hydrogen peroxide, but it’s not that antimicrobial and it can be drying if you use it for a long time," Dr. Ke said.

Acetic acid and sodium hypochlorite are antipseudomonal options.

Topical antibiotics for consideration include bacitracin and polymyxin B (Polysporin) and bacitracin, neomycin, and polymyxin B (Neosporin), but both carry the risk of allergic reactions, he said. He also said he often recommends petroleum-based ointments such Vaseline or Aquaphor.

Mupirocin 2% "is a favorite for granulating wounds on the lower extremities when you worry about gram-positive and gram-negative coverage. I typically use silver sulfadiazine 1%."

Dr. Ke uses nonstick pads to cover wounds and occlusive dressings to match the wound type, including polyurethane foams, polyurethane films, hydrocolloids, hydrogels, alginates, and Unna’s boot. He sees patients every 1-2 weeks if necessary to check their wounds, "but if they need to be seen more often I’m there for them. You want to be supportive. Excess fibrin and debris can form on the area."

The meeting was sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. Dr. Ke said that he had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

SAN DIEGO – Whether to stop anticoagulation therapy before dermatologic surgery can be a tricky call, said Dr. Tissa Hata.

Based on the serious nature of thrombotic complications and low risk of serious hemorrhagic complications, most clinicians would agree that patients on warfarin "should have therapy continued throughout the procedure and the INR [international normalized ratio] should be within the accepted therapeutic range – usually less than 3.0," Dr. Hata said at a meeting on superficial anatomy and cutaneous surgery, sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic.

Patients on aspirin, if medically necessary, "should be continued," advised Dr. Hata, professor of dermatology at the University of California, San Diego. "If aspirin is not medically necessary, the surgeon may choose to continue to discontinue. Always involve the prescribing physician in any decision to discontinue any of the medications."

She based her remarks in part on results from a prospective study of 5,950 skin cancer lesions excised in 2,394 patients (Br. J. Surg. 2007;94:1356-60). The rate of postoperative bleeding was 0.7% overall and 2.5% among the 320 patients who were taking warfarin.

The rate of bleeding was 1.0% for skin flap repairs, 0.4% for simple excision and closure, and 5.0% for skin grafts. Of the 40 cases of bleeding in the study, 26 were hemorrhages and 14 were hematomas. Three patients (two of whom were on warfarin) required exploration and one had vessel ligation. Two patients (neither of whom were on warfarin) had hematoma evacuation.

The following factors were associated with a significantly increased risk of bleeding: age greater than 67 years (odds ratio 4.7), being on warfarin therapy (OR 2.9), having undergone flap or graft surgery (OR 2.7), and having undergone ear surgery (OR 2.6).

A more recent meta-analysis representing 1,373 patients undergoing dermatologic surgery who were taking anticoagulant medications prior to surgery found that patients taking warfarin were nearly seven times more likely to have a moderate to severe complication, compared with controls (Dermatol. Surg. 2008;34:160-5). Patients taking aspirin were nearly twice as likely to have a moderate to severe complication, compared with controls.

"It does appear that warfarin and aspirin do increase your risk of bleeding and complications," Dr. Hata said. "What does that mean for us? Should we stop all of our aspirin and anticoagulants prior to procedures? What’s the risk of thrombotic complications when we stop their therapy?"

A review of studies associated with preoperative warfarin discontinuation found that the rates of thromboembolism range from 5.8%-47% within 1 month of stopping warfarin, while the yearly incidence of thromboembolism for patients with nonvalvular atrial fibrillation is 4.5% and 8% for patients with a mechanical heart valve (Dermatol. Surg. 2000;26:785-9).

According to a survey of 271 members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology, 126 complications were associated with discontinuing warfarin and aspirin, most notably stroke (39 cases), transient ischemic attack (25 cases), and myocardial infarction (19 cases). More than half of respondents (56%) said that they never stop warfarin therapy prior to surgery, 41% sometimes do, and 3% always do (Dermatol. Surg. 2007;33:1189-97). In addition, 63% said that they never discontinue medically necessary aspirin prior to surgery, 34% sometimes do, and 3% always do.

Dr. Hata said that she had no relevant financial conflicts to disclose.

More than a third of patients seeking cosmetic nose surgery have symptoms of body dysmorphic disorder, according to a preoperative study of 226 patients at a Belgian university hospital.

"This study shows that the prevalence of body dysmorphic disorder symptoms in a cosmetic rhinoplasty population is high and that the severity of symptoms has a clearly negative effect on daily functioning," wrote Dr. Valerie A. Picavet of University Hospitals Leuven (Belgium), and her associates.

©Amir Niknam Pirzadeh/ Stockphoto.com

The link between body dysmorphic disorder (BDD) and cosmetic surgery seekers is well documented (Body Image 2004;1:99-111; Br. J. Plast. Surg. 2003;56:546-51), but Dr. Picavet and her team focused on its prevalence among rhinoplasty seekers.

In collaboration with the psychiatric department of University Hospitals, the team conducted preoperative interviews with patients at a referral center for nasal disease. These patients were over age 16 years and seeking rhinoplasty for aesthetic and/or functional reasons. The same interviews were conducted in a 65-person control group not seeking rhinoplasty (Plast. Reconstr. Surg. 2011;128:509-17).

The researchers used the DSM-IV definition of BDD by which individuals have a preoccupation with an imagined or slight physical defect.

Individuals with this disorder devote a significant amount of time each day focused on their perceived defect, have daily distress about this concern, and suffer social impairment as a result of their preoccupation.

For this study, patients were given questionnaires to establish a clinical profile and evidence of BDD symptoms. They were asked to evaluate their nasal shape on a visual analog scale. In addition, they were given the Yale-Brown Obsessive Compulsive scale modified for BDD to rate BDD-related thoughts and behaviors. Social impairment was assessed with the Sheehan Disability Scale and the Derriford Appearance Scale.

The researchers accounted for the possibility that not every nasal shape defect is imaginary by developing a scoring system in which patients' noses were evaluated by two independent observers.

Each patient's nose was rated on a scale from severely deformed to zero deformity. But patients' evaluations of their own noses did not match these evaluations by the observers. No correlation was found between subjective and objective assessments of nasal deformity.

In all, 74 patients (33%) had at least moderate symptoms of BDD. These individuals scored 16 or higher on the Yale-Brown scale. There were no patients with the most extreme BDD symptoms. Among the control group, only one patient (2%) had moderate or higher BDD symptoms.

The reason patients gave for seeking rhinoplasty had a bearing on their likelihood of their having BDD symptoms. Among those seeking surgery for functional reasons, only 9 (12%) had moderate or higher symptoms of BDD. Among those seeking rhinoplasty for aesthetic reasons, 65 (43%) had moderate or higher symptoms of BDD. The correlation between Yale-Brown score and reason for seeking surgery was statistically significant (P < .001).

The correlation between having a previous rhinoplasty and BDD symptom severity also was statistically significant (P = .003). For surgeons screening rhinoplasty patients, a primarily aesthetic motivation or a history of previous rhinoplasty may be a red flag indicating that the patient should be carefully assessed for symptoms of BDD.

The study also found a statistically significant relationship between number of BDD symptoms and degree of social impairment and distress in these rhinoplasty-seeking patients. There was also a positive correlation between patients' Yale-Brown score, and psychiatric history and comorbidities.

The researchers conclude, "Thorough preoperative evaluation, including informing about psychiatric history, especially depression, should therefore be included in the preoperative assessment of cosmetic surgery patients, as it might be an indicator for latent body dysmorphic disorder."

Dr. Picavet and her team reported no financial interest in relation to this study and no outside funding was received.

More than a third of patients seeking cosmetic nose surgery have symptoms of body dysmorphic disorder, according to a preoperative study of 226 patients at a Belgian university hospital.

"This study shows that the prevalence of body dysmorphic disorder symptoms in a cosmetic rhinoplasty population is high and that the severity of symptoms has a clearly negative effect on daily functioning," wrote Dr. Valerie A. Picavet of University Hospitals Leuven (Belgium), and her associates.

©Amir Niknam Pirzadeh/ Stockphoto.com

The link between body dysmorphic disorder (BDD) and cosmetic surgery seekers is well documented (Body Image 2004;1:99-111; Br. J. Plast. Surg. 2003;56:546-51), but Dr. Picavet and her team focused on its prevalence among rhinoplasty seekers.

In collaboration with the psychiatric department of University Hospitals, the team conducted preoperative interviews with patients at a referral center for nasal disease. These patients were over age 16 years and seeking rhinoplasty for aesthetic and/or functional reasons. The same interviews were conducted in a 65-person control group not seeking rhinoplasty (Plast. Reconstr. Surg. 2011;128:509-17).

The researchers used the DSM-IV definition of BDD by which individuals have a preoccupation with an imagined or slight physical defect.

Individuals with this disorder devote a significant amount of time each day focused on their perceived defect, have daily distress about this concern, and suffer social impairment as a result of their preoccupation.

For this study, patients were given questionnaires to establish a clinical profile and evidence of BDD symptoms. They were asked to evaluate their nasal shape on a visual analog scale. In addition, they were given the Yale-Brown Obsessive Compulsive scale modified for BDD to rate BDD-related thoughts and behaviors. Social impairment was assessed with the Sheehan Disability Scale and the Derriford Appearance Scale.

The researchers accounted for the possibility that not every nasal shape defect is imaginary by developing a scoring system in which patients' noses were evaluated by two independent observers.

Each patient's nose was rated on a scale from severely deformed to zero deformity. But patients' evaluations of their own noses did not match these evaluations by the observers. No correlation was found between subjective and objective assessments of nasal deformity.

In all, 74 patients (33%) had at least moderate symptoms of BDD. These individuals scored 16 or higher on the Yale-Brown scale. There were no patients with the most extreme BDD symptoms. Among the control group, only one patient (2%) had moderate or higher BDD symptoms.

The reason patients gave for seeking rhinoplasty had a bearing on their likelihood of their having BDD symptoms. Among those seeking surgery for functional reasons, only 9 (12%) had moderate or higher symptoms of BDD. Among those seeking rhinoplasty for aesthetic reasons, 65 (43%) had moderate or higher symptoms of BDD. The correlation between Yale-Brown score and reason for seeking surgery was statistically significant (P < .001).

The correlation between having a previous rhinoplasty and BDD symptom severity also was statistically significant (P = .003). For surgeons screening rhinoplasty patients, a primarily aesthetic motivation or a history of previous rhinoplasty may be a red flag indicating that the patient should be carefully assessed for symptoms of BDD.

The study also found a statistically significant relationship between number of BDD symptoms and degree of social impairment and distress in these rhinoplasty-seeking patients. There was also a positive correlation between patients' Yale-Brown score, and psychiatric history and comorbidities.

The researchers conclude, "Thorough preoperative evaluation, including informing about psychiatric history, especially depression, should therefore be included in the preoperative assessment of cosmetic surgery patients, as it might be an indicator for latent body dysmorphic disorder."

Dr. Picavet and her team reported no financial interest in relation to this study and no outside funding was received.

More than a third of patients seeking cosmetic nose surgery have symptoms of body dysmorphic disorder, according to a preoperative study of 226 patients at a Belgian university hospital.

"This study shows that the prevalence of body dysmorphic disorder symptoms in a cosmetic rhinoplasty population is high and that the severity of symptoms has a clearly negative effect on daily functioning," wrote Dr. Valerie A. Picavet of University Hospitals Leuven (Belgium), and her associates.

©Amir Niknam Pirzadeh/ Stockphoto.com

The link between body dysmorphic disorder (BDD) and cosmetic surgery seekers is well documented (Body Image 2004;1:99-111; Br. J. Plast. Surg. 2003;56:546-51), but Dr. Picavet and her team focused on its prevalence among rhinoplasty seekers.

In collaboration with the psychiatric department of University Hospitals, the team conducted preoperative interviews with patients at a referral center for nasal disease. These patients were over age 16 years and seeking rhinoplasty for aesthetic and/or functional reasons. The same interviews were conducted in a 65-person control group not seeking rhinoplasty (Plast. Reconstr. Surg. 2011;128:509-17).

The researchers used the DSM-IV definition of BDD by which individuals have a preoccupation with an imagined or slight physical defect.

Individuals with this disorder devote a significant amount of time each day focused on their perceived defect, have daily distress about this concern, and suffer social impairment as a result of their preoccupation.

For this study, patients were given questionnaires to establish a clinical profile and evidence of BDD symptoms. They were asked to evaluate their nasal shape on a visual analog scale. In addition, they were given the Yale-Brown Obsessive Compulsive scale modified for BDD to rate BDD-related thoughts and behaviors. Social impairment was assessed with the Sheehan Disability Scale and the Derriford Appearance Scale.

The researchers accounted for the possibility that not every nasal shape defect is imaginary by developing a scoring system in which patients' noses were evaluated by two independent observers.

Each patient's nose was rated on a scale from severely deformed to zero deformity. But patients' evaluations of their own noses did not match these evaluations by the observers. No correlation was found between subjective and objective assessments of nasal deformity.

In all, 74 patients (33%) had at least moderate symptoms of BDD. These individuals scored 16 or higher on the Yale-Brown scale. There were no patients with the most extreme BDD symptoms. Among the control group, only one patient (2%) had moderate or higher BDD symptoms.

The reason patients gave for seeking rhinoplasty had a bearing on their likelihood of their having BDD symptoms. Among those seeking surgery for functional reasons, only 9 (12%) had moderate or higher symptoms of BDD. Among those seeking rhinoplasty for aesthetic reasons, 65 (43%) had moderate or higher symptoms of BDD. The correlation between Yale-Brown score and reason for seeking surgery was statistically significant (P < .001).

The correlation between having a previous rhinoplasty and BDD symptom severity also was statistically significant (P = .003). For surgeons screening rhinoplasty patients, a primarily aesthetic motivation or a history of previous rhinoplasty may be a red flag indicating that the patient should be carefully assessed for symptoms of BDD.

The study also found a statistically significant relationship between number of BDD symptoms and degree of social impairment and distress in these rhinoplasty-seeking patients. There was also a positive correlation between patients' Yale-Brown score, and psychiatric history and comorbidities.

The researchers conclude, "Thorough preoperative evaluation, including informing about psychiatric history, especially depression, should therefore be included in the preoperative assessment of cosmetic surgery patients, as it might be an indicator for latent body dysmorphic disorder."

Dr. Picavet and her team reported no financial interest in relation to this study and no outside funding was received.