Aesthetic Dermatology

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

The use of soap-like substances for cleansing dates back as early as 2,500 BCE, and soap itself is believed to have been invented between 600 and 300 BCE (Soap Technology for the 1900's, Champaign, Ill., American Oil Chemists' Society, 1990, p. 1–47).

Interestingly, though, the soap production process remained a carefully protected secret until it was detailed in a publication in 1775, eventually setting the stage for the soap industry (Dermatol. Ther. 2004;17 Suppl 1:35–42).

The oldest brand, Yardley, made by a small perfumery and soap business, was founded in 1779, but the first industrial manufacturer of soap in an individually wrapped and branded bar did not occur until 1884 in England (American Soap Makers Guide, New York, Henry Carey Baird & Co., 1928, p. 914–9).

The soap industry grew substantially during the 20th century, fueled by increasing interest in cleanliness and other health benefits of soap, as well as in soap's sensory pleasures (J. Am. Acad. Dermatol. 1979;1:35–41). Concurrently, interest in health and hygiene led to the development of deodorant soaps, while the desire for beautiful skin and aromas led to the development of cleansing bars of different colors, shapes, and fragrances.

Modern Cleansing Agents

Increased awareness of soap-induced skin irritation drove consumer demand in the 1940s for mild cleansing bars. The introduction of synthetic detergents into the cleansing arena in 1948 led to the development of patently milder cleansing bars that were better for the skin than soaps (J. Am. Acad. Dermatol. 1979;1:35–41).

Mild cleansers have represented an increasing proportion of the cleanser market in recent years, and interest is growing in the functional benefits, especially moisturizing. Greater understanding of the effects of cleansing agents on skin and the use of milder surfactants and polymers have led to novel approaches to the delivery of skin care benefits from cleansers (Dry Skin and Moisturizers: Chemistry and Function, 2nd ed., Boca Raton, CRC Press, 2006, p. 405–28).

Hand washing is integral to personal hygiene and helps prevent infectious germ transmission, but frequent hand washing, of course, can itself lead to dry, damaged, and irritated skin (Contact Dermatitis 1995;32:225–32). Gentle cleansers and moisturizers are recommended to maintain a healthy skin barrier in these cases.

Facial cleansing is typically associated with freshening and improving appearance, including the removal of “oily” residues (including make-up) without damaging the skin. Foaming (surfactant-containing) and nonfoaming (low- to no-surfactant) systems and towelettes represent the currently available facial cleansing products (Dermatol. Ther. 2004;17 Suppl 1:35–42). Nonfoaming agents are usually mild but less efficient cleansers. Cleansing towelettes are convenient and easy to use.

Surfactants

Surfactants are the primary active ingredients in cleanser formulations, controlling the degree of mildness or irritancy of a product. The chief surfactants used in cleansers are anionic, because of their ideal foam and lather characteristics.

Soap (alkyl carboxylate) is the main surfactant used in most cleansing bars. Typically, soap is produced by saponification, which involves a reaction of a triglyceride oil/fat with an alkali. The oils most often used are vegetable oils, such as palm oil, palm oil derivatives (palm stearine, palm olein), rice bran oil, ground nut oil, and castor oil combined with coconut oil or palm kernel oil (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Nonvegetable ingredients used in soap are generally derived from animal fat, such as tallow. Although soaps are effective cleansers, they are known to irritate the skin, eliciting reactions such as erythema, xerosis, and pruritus, particularly in cold weather (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Newer classes of soaps—superfatted soaps, transparent soaps, and combination bars—have been developed to mitigate the irritancy of soaps, which is associated with poor rinsability and a high pH (Dermatol. Ther. 2004;17 Suppl 1:35–42; Cosmetics Toiletries 1995;110:89):

• Superfatted soaps. These are derived from incomplete saponification (neutralization), which is achieved by leaving unreacted fatty acids or oils in the product or by adding fatty alcohols, fatty acids, or esters during manufacturing. Superfatting usually enhances soap product characteristics, including mildness, moisturization, lather, mush value, and wear rate (Dermatol. Ther. 2004;17 Suppl 1:35–42; Indian J. Pediatr. 2002;69:767–9; The Manufacture of Soaps, Other Detergents and Glycerin, West Sussex, U.K., Ellis Horwood Limited, 1985).
• Transparent soaps. Made with a high level of humectants that tend to solubilize the soaps, leaving a transparent, clear appearance, transparent soaps also have high levels of active soap and an alkaline pH, which tend to promote irritancy. These products are usually mild, however, because of the presence of glycerin and low levels of fatty acids (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Combination bars. These cleansing agents combine natural soaps with milder synthetic surfactants and typically cause less irritation than normal soaps. Although the pH of these products is in the high range, the synthetic surfactants tend to suppress irritancy (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Synthetic detergent bars. Syndet bars, unlike soaps, are produced through esterification, ethoxylation, and sulfonation of oils, fats, or petroleum products, and are formulated in the neutral pH range. The synthetic surfactants frequently used in these bars include alkyl glyceryl ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate (Dermatol. Ther. 2004;17 Suppl 1:35–42). The unique molecular characteristics of sodium cocoyl isethionate have significantly contributed to the mildness of cleansing bars.

Cleansing Liquid Surfactants

Liquid cleansers often combine anionic and amphoteric surfactants. Anionic surfactants commonly used in liquid cleansers include soaps (salts of fatty acids) and synthetic surfactants such as alkyl ether sulfate, alkyl acyl isethionates, alkyl phosphates, alkyl sulfosuccinates, and alkyl sulfonates. Cocoamidopropyl betaine and cocoamphoacetate are the typical amphoteric or zwitterionic surfactants used.

Notably, nonionic surfactants such as alkyl polyglucoside and amino acid-based surfactants like acyl glycinates, alkyl glutamates, and sarcosinates are being increasingly incorporated as primary surfactants in cleanser systems for their mildness-enhancing activity (Surfactants in Cosmetics, New York, Marcel Dekker, 1997, pp. 427–71).

Although most liquid cleansers are formulated in the neutral to acidic pH range, products that contain soap (alkyl carboxylate) as the main active ingredient typically exhibit an alkaline pH.

Structurants and Other Ingredients

With cleansing bars, structurants such as long-chain fatty acids, waxes, and alkyl esters are necessary to maintain the solid format and facilitate the complex manufacturing process. In liquids, structurants impart the right rheology and consistency to the product for optimal dispensing and in-use experience. Structurants also ensure the physical stability of dispersed and suspended phases and confer moisturizing effects.

A moisturizing effect is provided in cleansing systems by water-soluble humectants such as glycerin. Emollients are included in cleansers to reduce the drying effects of surfactants. In moisturizing shower gels, typical emollients and occlusives include triglyceride oils, lipids, petrolatum, waxes, and mineral oil.

Other functional ingredients may be found in cleansers formulated for specific benefits. For example, bactericidal actives such as triclosan or triclocarban are contained in antimicrobial cleansers.

The Food and Drug Administration regulates synthetic cleansers and those designed to achieve antibacterial or other druglike effects. The Consumer Product Safety Commission regulates pure soap products.

Mild, Moisturizing, Cleansing Agents

Delivering lipids, emollient oils, and occlusives under cleansing conditions is one of the primary approaches to reducing visible signs of skin dryness and improving hydration. Incorporating high levels of emollients into a stable cleansing formulation and depositing the emollients on the skin during washing are achieved through specially structured surfactant formulations with cationic polymers to aid deposition and retention of oils and occlusives.

Emollient and occlusive ingredients used in cleansing liquid formulations include vegetable oils (soybean or sunflower seed) and petroleum jelly.

Hydrophobic emollients are more often included in cleansers because they are easier to deliver to skin than water-soluble moisturizers such as glycerin and other humectants.

Paradoxically, cleansing often leads to a weakening of the skin barrier. Consequently, for most skin disorders, cleansing with commonly used soap-based products may prove problematic and aggravate a patient's particular skin condition. In addition, prolonged daily use of cleansers that induce short-term damage can lead to xerosis, scaling, flaking, erythema, and pruritus. Therefore, mild cleansing is recommended for the management of compromised skin conditions such as acne, rosacea, atopic dermatitis, and photodamage.

Conclusion

Soap has an interesting and extensive history and has long been the primary cleansing agent. In recent decades, innovations have led to a marked increase in the variety and versatility of products used for cleansing and beautifying purposes.

Underlying many of these developments was the motivation to formulate products that would not cause irritation. Subsequently, agents have been developed that are more suitable for use on dry or sensitive skin or with compromised skin conditions.

Antibacterial soaps have also been formulated, but could conceivably contribute to the growing problem of antibacterial resistance. This information is available in more detail in the second edition of my book, “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill Professional, 2009).

The use of soap-like substances for cleansing dates back as early as 2,500 BCE, and soap itself is believed to have been invented between 600 and 300 BCE (Soap Technology for the 1900's, Champaign, Ill., American Oil Chemists' Society, 1990, p. 1–47).

Interestingly, though, the soap production process remained a carefully protected secret until it was detailed in a publication in 1775, eventually setting the stage for the soap industry (Dermatol. Ther. 2004;17 Suppl 1:35–42).

The oldest brand, Yardley, made by a small perfumery and soap business, was founded in 1779, but the first industrial manufacturer of soap in an individually wrapped and branded bar did not occur until 1884 in England (American Soap Makers Guide, New York, Henry Carey Baird & Co., 1928, p. 914–9).

The soap industry grew substantially during the 20th century, fueled by increasing interest in cleanliness and other health benefits of soap, as well as in soap's sensory pleasures (J. Am. Acad. Dermatol. 1979;1:35–41). Concurrently, interest in health and hygiene led to the development of deodorant soaps, while the desire for beautiful skin and aromas led to the development of cleansing bars of different colors, shapes, and fragrances.

Modern Cleansing Agents

Increased awareness of soap-induced skin irritation drove consumer demand in the 1940s for mild cleansing bars. The introduction of synthetic detergents into the cleansing arena in 1948 led to the development of patently milder cleansing bars that were better for the skin than soaps (J. Am. Acad. Dermatol. 1979;1:35–41).

Mild cleansers have represented an increasing proportion of the cleanser market in recent years, and interest is growing in the functional benefits, especially moisturizing. Greater understanding of the effects of cleansing agents on skin and the use of milder surfactants and polymers have led to novel approaches to the delivery of skin care benefits from cleansers (Dry Skin and Moisturizers: Chemistry and Function, 2nd ed., Boca Raton, CRC Press, 2006, p. 405–28).

Hand washing is integral to personal hygiene and helps prevent infectious germ transmission, but frequent hand washing, of course, can itself lead to dry, damaged, and irritated skin (Contact Dermatitis 1995;32:225–32). Gentle cleansers and moisturizers are recommended to maintain a healthy skin barrier in these cases.

Facial cleansing is typically associated with freshening and improving appearance, including the removal of “oily” residues (including make-up) without damaging the skin. Foaming (surfactant-containing) and nonfoaming (low- to no-surfactant) systems and towelettes represent the currently available facial cleansing products (Dermatol. Ther. 2004;17 Suppl 1:35–42). Nonfoaming agents are usually mild but less efficient cleansers. Cleansing towelettes are convenient and easy to use.

Surfactants

Surfactants are the primary active ingredients in cleanser formulations, controlling the degree of mildness or irritancy of a product. The chief surfactants used in cleansers are anionic, because of their ideal foam and lather characteristics.

Soap (alkyl carboxylate) is the main surfactant used in most cleansing bars. Typically, soap is produced by saponification, which involves a reaction of a triglyceride oil/fat with an alkali. The oils most often used are vegetable oils, such as palm oil, palm oil derivatives (palm stearine, palm olein), rice bran oil, ground nut oil, and castor oil combined with coconut oil or palm kernel oil (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Nonvegetable ingredients used in soap are generally derived from animal fat, such as tallow. Although soaps are effective cleansers, they are known to irritate the skin, eliciting reactions such as erythema, xerosis, and pruritus, particularly in cold weather (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Newer classes of soaps—superfatted soaps, transparent soaps, and combination bars—have been developed to mitigate the irritancy of soaps, which is associated with poor rinsability and a high pH (Dermatol. Ther. 2004;17 Suppl 1:35–42; Cosmetics Toiletries 1995;110:89):

• Superfatted soaps. These are derived from incomplete saponification (neutralization), which is achieved by leaving unreacted fatty acids or oils in the product or by adding fatty alcohols, fatty acids, or esters during manufacturing. Superfatting usually enhances soap product characteristics, including mildness, moisturization, lather, mush value, and wear rate (Dermatol. Ther. 2004;17 Suppl 1:35–42; Indian J. Pediatr. 2002;69:767–9; The Manufacture of Soaps, Other Detergents and Glycerin, West Sussex, U.K., Ellis Horwood Limited, 1985).
• Transparent soaps. Made with a high level of humectants that tend to solubilize the soaps, leaving a transparent, clear appearance, transparent soaps also have high levels of active soap and an alkaline pH, which tend to promote irritancy. These products are usually mild, however, because of the presence of glycerin and low levels of fatty acids (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Combination bars. These cleansing agents combine natural soaps with milder synthetic surfactants and typically cause less irritation than normal soaps. Although the pH of these products is in the high range, the synthetic surfactants tend to suppress irritancy (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Synthetic detergent bars. Syndet bars, unlike soaps, are produced through esterification, ethoxylation, and sulfonation of oils, fats, or petroleum products, and are formulated in the neutral pH range. The synthetic surfactants frequently used in these bars include alkyl glyceryl ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate (Dermatol. Ther. 2004;17 Suppl 1:35–42). The unique molecular characteristics of sodium cocoyl isethionate have significantly contributed to the mildness of cleansing bars.

Cleansing Liquid Surfactants

Liquid cleansers often combine anionic and amphoteric surfactants. Anionic surfactants commonly used in liquid cleansers include soaps (salts of fatty acids) and synthetic surfactants such as alkyl ether sulfate, alkyl acyl isethionates, alkyl phosphates, alkyl sulfosuccinates, and alkyl sulfonates. Cocoamidopropyl betaine and cocoamphoacetate are the typical amphoteric or zwitterionic surfactants used.

Notably, nonionic surfactants such as alkyl polyglucoside and amino acid-based surfactants like acyl glycinates, alkyl glutamates, and sarcosinates are being increasingly incorporated as primary surfactants in cleanser systems for their mildness-enhancing activity (Surfactants in Cosmetics, New York, Marcel Dekker, 1997, pp. 427–71).

Although most liquid cleansers are formulated in the neutral to acidic pH range, products that contain soap (alkyl carboxylate) as the main active ingredient typically exhibit an alkaline pH.

Structurants and Other Ingredients

With cleansing bars, structurants such as long-chain fatty acids, waxes, and alkyl esters are necessary to maintain the solid format and facilitate the complex manufacturing process. In liquids, structurants impart the right rheology and consistency to the product for optimal dispensing and in-use experience. Structurants also ensure the physical stability of dispersed and suspended phases and confer moisturizing effects.

A moisturizing effect is provided in cleansing systems by water-soluble humectants such as glycerin. Emollients are included in cleansers to reduce the drying effects of surfactants. In moisturizing shower gels, typical emollients and occlusives include triglyceride oils, lipids, petrolatum, waxes, and mineral oil.

Other functional ingredients may be found in cleansers formulated for specific benefits. For example, bactericidal actives such as triclosan or triclocarban are contained in antimicrobial cleansers.

The Food and Drug Administration regulates synthetic cleansers and those designed to achieve antibacterial or other druglike effects. The Consumer Product Safety Commission regulates pure soap products.

Mild, Moisturizing, Cleansing Agents

Delivering lipids, emollient oils, and occlusives under cleansing conditions is one of the primary approaches to reducing visible signs of skin dryness and improving hydration. Incorporating high levels of emollients into a stable cleansing formulation and depositing the emollients on the skin during washing are achieved through specially structured surfactant formulations with cationic polymers to aid deposition and retention of oils and occlusives.

Emollient and occlusive ingredients used in cleansing liquid formulations include vegetable oils (soybean or sunflower seed) and petroleum jelly.

Hydrophobic emollients are more often included in cleansers because they are easier to deliver to skin than water-soluble moisturizers such as glycerin and other humectants.

Paradoxically, cleansing often leads to a weakening of the skin barrier. Consequently, for most skin disorders, cleansing with commonly used soap-based products may prove problematic and aggravate a patient's particular skin condition. In addition, prolonged daily use of cleansers that induce short-term damage can lead to xerosis, scaling, flaking, erythema, and pruritus. Therefore, mild cleansing is recommended for the management of compromised skin conditions such as acne, rosacea, atopic dermatitis, and photodamage.

Conclusion

Soap has an interesting and extensive history and has long been the primary cleansing agent. In recent decades, innovations have led to a marked increase in the variety and versatility of products used for cleansing and beautifying purposes.

Underlying many of these developments was the motivation to formulate products that would not cause irritation. Subsequently, agents have been developed that are more suitable for use on dry or sensitive skin or with compromised skin conditions.

Antibacterial soaps have also been formulated, but could conceivably contribute to the growing problem of antibacterial resistance. This information is available in more detail in the second edition of my book, “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill Professional, 2009).

The use of soap-like substances for cleansing dates back as early as 2,500 BCE, and soap itself is believed to have been invented between 600 and 300 BCE (Soap Technology for the 1900's, Champaign, Ill., American Oil Chemists' Society, 1990, p. 1–47).

Interestingly, though, the soap production process remained a carefully protected secret until it was detailed in a publication in 1775, eventually setting the stage for the soap industry (Dermatol. Ther. 2004;17 Suppl 1:35–42).

The oldest brand, Yardley, made by a small perfumery and soap business, was founded in 1779, but the first industrial manufacturer of soap in an individually wrapped and branded bar did not occur until 1884 in England (American Soap Makers Guide, New York, Henry Carey Baird & Co., 1928, p. 914–9).

The soap industry grew substantially during the 20th century, fueled by increasing interest in cleanliness and other health benefits of soap, as well as in soap's sensory pleasures (J. Am. Acad. Dermatol. 1979;1:35–41). Concurrently, interest in health and hygiene led to the development of deodorant soaps, while the desire for beautiful skin and aromas led to the development of cleansing bars of different colors, shapes, and fragrances.

Modern Cleansing Agents

Increased awareness of soap-induced skin irritation drove consumer demand in the 1940s for mild cleansing bars. The introduction of synthetic detergents into the cleansing arena in 1948 led to the development of patently milder cleansing bars that were better for the skin than soaps (J. Am. Acad. Dermatol. 1979;1:35–41).

Mild cleansers have represented an increasing proportion of the cleanser market in recent years, and interest is growing in the functional benefits, especially moisturizing. Greater understanding of the effects of cleansing agents on skin and the use of milder surfactants and polymers have led to novel approaches to the delivery of skin care benefits from cleansers (Dry Skin and Moisturizers: Chemistry and Function, 2nd ed., Boca Raton, CRC Press, 2006, p. 405–28).

Hand washing is integral to personal hygiene and helps prevent infectious germ transmission, but frequent hand washing, of course, can itself lead to dry, damaged, and irritated skin (Contact Dermatitis 1995;32:225–32). Gentle cleansers and moisturizers are recommended to maintain a healthy skin barrier in these cases.

Facial cleansing is typically associated with freshening and improving appearance, including the removal of “oily” residues (including make-up) without damaging the skin. Foaming (surfactant-containing) and nonfoaming (low- to no-surfactant) systems and towelettes represent the currently available facial cleansing products (Dermatol. Ther. 2004;17 Suppl 1:35–42). Nonfoaming agents are usually mild but less efficient cleansers. Cleansing towelettes are convenient and easy to use.

Surfactants

Surfactants are the primary active ingredients in cleanser formulations, controlling the degree of mildness or irritancy of a product. The chief surfactants used in cleansers are anionic, because of their ideal foam and lather characteristics.

Soap (alkyl carboxylate) is the main surfactant used in most cleansing bars. Typically, soap is produced by saponification, which involves a reaction of a triglyceride oil/fat with an alkali. The oils most often used are vegetable oils, such as palm oil, palm oil derivatives (palm stearine, palm olein), rice bran oil, ground nut oil, and castor oil combined with coconut oil or palm kernel oil (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Nonvegetable ingredients used in soap are generally derived from animal fat, such as tallow. Although soaps are effective cleansers, they are known to irritate the skin, eliciting reactions such as erythema, xerosis, and pruritus, particularly in cold weather (Dermatol. Ther. 2004;17 Suppl 1:35–42).

Newer classes of soaps—superfatted soaps, transparent soaps, and combination bars—have been developed to mitigate the irritancy of soaps, which is associated with poor rinsability and a high pH (Dermatol. Ther. 2004;17 Suppl 1:35–42; Cosmetics Toiletries 1995;110:89):

• Superfatted soaps. These are derived from incomplete saponification (neutralization), which is achieved by leaving unreacted fatty acids or oils in the product or by adding fatty alcohols, fatty acids, or esters during manufacturing. Superfatting usually enhances soap product characteristics, including mildness, moisturization, lather, mush value, and wear rate (Dermatol. Ther. 2004;17 Suppl 1:35–42; Indian J. Pediatr. 2002;69:767–9; The Manufacture of Soaps, Other Detergents and Glycerin, West Sussex, U.K., Ellis Horwood Limited, 1985).
• Transparent soaps. Made with a high level of humectants that tend to solubilize the soaps, leaving a transparent, clear appearance, transparent soaps also have high levels of active soap and an alkaline pH, which tend to promote irritancy. These products are usually mild, however, because of the presence of glycerin and low levels of fatty acids (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Combination bars. These cleansing agents combine natural soaps with milder synthetic surfactants and typically cause less irritation than normal soaps. Although the pH of these products is in the high range, the synthetic surfactants tend to suppress irritancy (Dermatol. Ther. 2004;17 Suppl 1:35–42).
• Synthetic detergent bars. Syndet bars, unlike soaps, are produced through esterification, ethoxylation, and sulfonation of oils, fats, or petroleum products, and are formulated in the neutral pH range. The synthetic surfactants frequently used in these bars include alkyl glyceryl ether sulfonate, alpha olefin sulfonates, betaines, sulfosuccinates, sodium cocoyl monoglyceride sulfate, and sodium cocoyl isethionate (Dermatol. Ther. 2004;17 Suppl 1:35–42). The unique molecular characteristics of sodium cocoyl isethionate have significantly contributed to the mildness of cleansing bars.

Cleansing Liquid Surfactants

Liquid cleansers often combine anionic and amphoteric surfactants. Anionic surfactants commonly used in liquid cleansers include soaps (salts of fatty acids) and synthetic surfactants such as alkyl ether sulfate, alkyl acyl isethionates, alkyl phosphates, alkyl sulfosuccinates, and alkyl sulfonates. Cocoamidopropyl betaine and cocoamphoacetate are the typical amphoteric or zwitterionic surfactants used.

Notably, nonionic surfactants such as alkyl polyglucoside and amino acid-based surfactants like acyl glycinates, alkyl glutamates, and sarcosinates are being increasingly incorporated as primary surfactants in cleanser systems for their mildness-enhancing activity (Surfactants in Cosmetics, New York, Marcel Dekker, 1997, pp. 427–71).

Although most liquid cleansers are formulated in the neutral to acidic pH range, products that contain soap (alkyl carboxylate) as the main active ingredient typically exhibit an alkaline pH.

Structurants and Other Ingredients

With cleansing bars, structurants such as long-chain fatty acids, waxes, and alkyl esters are necessary to maintain the solid format and facilitate the complex manufacturing process. In liquids, structurants impart the right rheology and consistency to the product for optimal dispensing and in-use experience. Structurants also ensure the physical stability of dispersed and suspended phases and confer moisturizing effects.

A moisturizing effect is provided in cleansing systems by water-soluble humectants such as glycerin. Emollients are included in cleansers to reduce the drying effects of surfactants. In moisturizing shower gels, typical emollients and occlusives include triglyceride oils, lipids, petrolatum, waxes, and mineral oil.

Other functional ingredients may be found in cleansers formulated for specific benefits. For example, bactericidal actives such as triclosan or triclocarban are contained in antimicrobial cleansers.

The Food and Drug Administration regulates synthetic cleansers and those designed to achieve antibacterial or other druglike effects. The Consumer Product Safety Commission regulates pure soap products.

Mild, Moisturizing, Cleansing Agents

Delivering lipids, emollient oils, and occlusives under cleansing conditions is one of the primary approaches to reducing visible signs of skin dryness and improving hydration. Incorporating high levels of emollients into a stable cleansing formulation and depositing the emollients on the skin during washing are achieved through specially structured surfactant formulations with cationic polymers to aid deposition and retention of oils and occlusives.

Emollient and occlusive ingredients used in cleansing liquid formulations include vegetable oils (soybean or sunflower seed) and petroleum jelly.

Hydrophobic emollients are more often included in cleansers because they are easier to deliver to skin than water-soluble moisturizers such as glycerin and other humectants.

Paradoxically, cleansing often leads to a weakening of the skin barrier. Consequently, for most skin disorders, cleansing with commonly used soap-based products may prove problematic and aggravate a patient's particular skin condition. In addition, prolonged daily use of cleansers that induce short-term damage can lead to xerosis, scaling, flaking, erythema, and pruritus. Therefore, mild cleansing is recommended for the management of compromised skin conditions such as acne, rosacea, atopic dermatitis, and photodamage.

Conclusion

Soap has an interesting and extensive history and has long been the primary cleansing agent. In recent decades, innovations have led to a marked increase in the variety and versatility of products used for cleansing and beautifying purposes.

Underlying many of these developments was the motivation to formulate products that would not cause irritation. Subsequently, agents have been developed that are more suitable for use on dry or sensitive skin or with compromised skin conditions.

Antibacterial soaps have also been formulated, but could conceivably contribute to the growing problem of antibacterial resistance. This information is available in more detail in the second edition of my book, “Cosmetic Dermatology: Principles and Practice” (McGraw-Hill Professional, 2009).

By David J. Goldberg, M.D. 

Should dermatologic surgeons teach nonphysicians to perform dermatologic surgery? I think the question is no longer relevant.

This question was debated at the 2008 annual meeting of the American Society for Dermatologic Surgery, with compelling arguments both for and against the practice.

The fact of the matter is that non-MDs are already doing dermatologic surgery, with or without our teaching. This is not something we can stop. This cat is out of the bag.

The least we can do is make sure these non-MDs are well trained. After all, we are the experts. We have the know-how and the skills, and it behooves us to pass this knowledge on to our high-level physician-supervised physician assistants and nurse practitioners so that we can provide the best and safest care for our patients.

According to the American Society for Aesthetic Plastic Surgery (ASAPS), Americans spent approximately $13.2 billion dollars on cosmetic procedures in plastic-surgery offices in 2007; $4.7 billion dollars were spent for nonsurgical procedures.

ASAPS also found that the top nonsurgical cosmetic procedures in 2007 were botulinum toxin injections (2,775,176 procedures), hyaluronic acid fillers (1,448,716 procedures), laser hair removal (1,412,657 procedures), microdermabrasion (829,658 procedures), and intense pulsed light (IPL) treatment (647,707 procedures).

It's no wonder that we rely more and more on physician extenders to help us keep up with the demand for cosmetic services. In 2002, the American Academy of Dermatology reported that 20% of dermatologists were using NPs and PAs in their practices. In 2007, it was 30%, and by 2010, it is estimated that 36% of dermatologists will be using NPs and PAs.

Physician assistants have developed a critical role in medical practices. Currently there are 68,000 PAs in the country, and it is projected that by the year 2016 the number will be 83,000. And patients are going to PAs in greater numbers.

According to the American Academy of Physician Assistants, there were 14 million more patient visits to PAs in 2007 than there were in 2006. That is not going to change. In fact, being a PA in a dermatologist's office is very lucrative. The mean salary is $103,000 per year in a dermatology practice, making derm PAs among the most highly paid in the field. It's a win-win situation for all—physicians in dermatology and plastic surgery are finding the physician-PA team helpful for maintaining a successful aesthetic practice.

The American Academy of Dermatology and American Society of Dermatologic Surgery guidelines state that PAs must work under the direct supervision of a physician. Nevertheless, according to an ASDS survey, 51% of dermatologists have seen complications from botched procedures performed by PAs who did not have physician supervision.

Among the most notable: A 22-year-old North Carolina State University biochemistry senior died from lidocaine toxicity after a potent topical anesthesia was applied for laser hair removal of the legs, and a 25-year-old Arizona woman died after languishing for 2 years on a respirator as a result of having her legs smeared with Photocaine (6% lidocaine, 6% tetracaine) ointment and then occluded with cellophane for several hours. Both of these cases involved nonmedical personnel.

There is a consensus among PAs that they are not being trained well by their supervising doctors. They are excluded from the ASDS meeting, and they certainly don't get to see approaches from any other physicians. But there are plenty of other meetings for nonphysicians where they can learn injectables, fillers, and lasers.

We can censure dermatologists who train their own PAs and NPs on how to inject botulinum toxin fillers and perform other cosmetic procedures. We can continue to cover our eyes and ears and pretend that we can stop this. Or we can consider training our PAs and NPs ourselves.

I say we should take the bull by the horns. We should train high-level physician extenders to meet our high standards. We should continue to push for legislation to encourage physician supervision, and we should promote the high quality of who we are and what we do as dermatologic surgeons.

Dr. David J. Goldberg is director of the Skin Laser and Surgery Specialists of NY/NJ, clinical professor of dermatology and director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York, and an adjunct professor of law at Fordham Law School, New York.

By David J. Goldberg, M.D. 

Should dermatologic surgeons teach nonphysicians to perform dermatologic surgery? I think the question is no longer relevant.

This question was debated at the 2008 annual meeting of the American Society for Dermatologic Surgery, with compelling arguments both for and against the practice.

The fact of the matter is that non-MDs are already doing dermatologic surgery, with or without our teaching. This is not something we can stop. This cat is out of the bag.

The least we can do is make sure these non-MDs are well trained. After all, we are the experts. We have the know-how and the skills, and it behooves us to pass this knowledge on to our high-level physician-supervised physician assistants and nurse practitioners so that we can provide the best and safest care for our patients.

According to the American Society for Aesthetic Plastic Surgery (ASAPS), Americans spent approximately $13.2 billion dollars on cosmetic procedures in plastic-surgery offices in 2007; $4.7 billion dollars were spent for nonsurgical procedures.

ASAPS also found that the top nonsurgical cosmetic procedures in 2007 were botulinum toxin injections (2,775,176 procedures), hyaluronic acid fillers (1,448,716 procedures), laser hair removal (1,412,657 procedures), microdermabrasion (829,658 procedures), and intense pulsed light (IPL) treatment (647,707 procedures).

It's no wonder that we rely more and more on physician extenders to help us keep up with the demand for cosmetic services. In 2002, the American Academy of Dermatology reported that 20% of dermatologists were using NPs and PAs in their practices. In 2007, it was 30%, and by 2010, it is estimated that 36% of dermatologists will be using NPs and PAs.

Physician assistants have developed a critical role in medical practices. Currently there are 68,000 PAs in the country, and it is projected that by the year 2016 the number will be 83,000. And patients are going to PAs in greater numbers.

According to the American Academy of Physician Assistants, there were 14 million more patient visits to PAs in 2007 than there were in 2006. That is not going to change. In fact, being a PA in a dermatologist's office is very lucrative. The mean salary is $103,000 per year in a dermatology practice, making derm PAs among the most highly paid in the field. It's a win-win situation for all—physicians in dermatology and plastic surgery are finding the physician-PA team helpful for maintaining a successful aesthetic practice.

The American Academy of Dermatology and American Society of Dermatologic Surgery guidelines state that PAs must work under the direct supervision of a physician. Nevertheless, according to an ASDS survey, 51% of dermatologists have seen complications from botched procedures performed by PAs who did not have physician supervision.

Among the most notable: A 22-year-old North Carolina State University biochemistry senior died from lidocaine toxicity after a potent topical anesthesia was applied for laser hair removal of the legs, and a 25-year-old Arizona woman died after languishing for 2 years on a respirator as a result of having her legs smeared with Photocaine (6% lidocaine, 6% tetracaine) ointment and then occluded with cellophane for several hours. Both of these cases involved nonmedical personnel.

There is a consensus among PAs that they are not being trained well by their supervising doctors. They are excluded from the ASDS meeting, and they certainly don't get to see approaches from any other physicians. But there are plenty of other meetings for nonphysicians where they can learn injectables, fillers, and lasers.

We can censure dermatologists who train their own PAs and NPs on how to inject botulinum toxin fillers and perform other cosmetic procedures. We can continue to cover our eyes and ears and pretend that we can stop this. Or we can consider training our PAs and NPs ourselves.

I say we should take the bull by the horns. We should train high-level physician extenders to meet our high standards. We should continue to push for legislation to encourage physician supervision, and we should promote the high quality of who we are and what we do as dermatologic surgeons.

Dr. David J. Goldberg is director of the Skin Laser and Surgery Specialists of NY/NJ, clinical professor of dermatology and director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York, and an adjunct professor of law at Fordham Law School, New York.

By David J. Goldberg, M.D. 

Should dermatologic surgeons teach nonphysicians to perform dermatologic surgery? I think the question is no longer relevant.

This question was debated at the 2008 annual meeting of the American Society for Dermatologic Surgery, with compelling arguments both for and against the practice.

The fact of the matter is that non-MDs are already doing dermatologic surgery, with or without our teaching. This is not something we can stop. This cat is out of the bag.

The least we can do is make sure these non-MDs are well trained. After all, we are the experts. We have the know-how and the skills, and it behooves us to pass this knowledge on to our high-level physician-supervised physician assistants and nurse practitioners so that we can provide the best and safest care for our patients.

According to the American Society for Aesthetic Plastic Surgery (ASAPS), Americans spent approximately $13.2 billion dollars on cosmetic procedures in plastic-surgery offices in 2007; $4.7 billion dollars were spent for nonsurgical procedures.

ASAPS also found that the top nonsurgical cosmetic procedures in 2007 were botulinum toxin injections (2,775,176 procedures), hyaluronic acid fillers (1,448,716 procedures), laser hair removal (1,412,657 procedures), microdermabrasion (829,658 procedures), and intense pulsed light (IPL) treatment (647,707 procedures).

It's no wonder that we rely more and more on physician extenders to help us keep up with the demand for cosmetic services. In 2002, the American Academy of Dermatology reported that 20% of dermatologists were using NPs and PAs in their practices. In 2007, it was 30%, and by 2010, it is estimated that 36% of dermatologists will be using NPs and PAs.

Physician assistants have developed a critical role in medical practices. Currently there are 68,000 PAs in the country, and it is projected that by the year 2016 the number will be 83,000. And patients are going to PAs in greater numbers.

According to the American Academy of Physician Assistants, there were 14 million more patient visits to PAs in 2007 than there were in 2006. That is not going to change. In fact, being a PA in a dermatologist's office is very lucrative. The mean salary is $103,000 per year in a dermatology practice, making derm PAs among the most highly paid in the field. It's a win-win situation for all—physicians in dermatology and plastic surgery are finding the physician-PA team helpful for maintaining a successful aesthetic practice.

The American Academy of Dermatology and American Society of Dermatologic Surgery guidelines state that PAs must work under the direct supervision of a physician. Nevertheless, according to an ASDS survey, 51% of dermatologists have seen complications from botched procedures performed by PAs who did not have physician supervision.

Among the most notable: A 22-year-old North Carolina State University biochemistry senior died from lidocaine toxicity after a potent topical anesthesia was applied for laser hair removal of the legs, and a 25-year-old Arizona woman died after languishing for 2 years on a respirator as a result of having her legs smeared with Photocaine (6% lidocaine, 6% tetracaine) ointment and then occluded with cellophane for several hours. Both of these cases involved nonmedical personnel.

There is a consensus among PAs that they are not being trained well by their supervising doctors. They are excluded from the ASDS meeting, and they certainly don't get to see approaches from any other physicians. But there are plenty of other meetings for nonphysicians where they can learn injectables, fillers, and lasers.

We can censure dermatologists who train their own PAs and NPs on how to inject botulinum toxin fillers and perform other cosmetic procedures. We can continue to cover our eyes and ears and pretend that we can stop this. Or we can consider training our PAs and NPs ourselves.

I say we should take the bull by the horns. We should train high-level physician extenders to meet our high standards. We should continue to push for legislation to encourage physician supervision, and we should promote the high quality of who we are and what we do as dermatologic surgeons.

Dr. David J. Goldberg is director of the Skin Laser and Surgery Specialists of NY/NJ, clinical professor of dermatology and director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York, and an adjunct professor of law at Fordham Law School, New York.

Daniel Barolet, MD

Light-emitting diode photobiomodulation is the newest category of nonthermal light therapies to find its way to the dermatologic armamentarium. In this article, we briefly review the literature on the development of this technology, its evolution within esthetic and medical dermatology, and provide practical and technical considerations for use in various conditions. This article also focuses on the specific cell-signaling pathways involved and how the mechanisms at play can be put to use to treat a variety of cutaneous problems as a stand-alone application and/or complementary treatment modality or as one of the best photodynamic therapy light source.

*For a PDF of the full article, click on the link to the left of this introduction.

Daniel Barolet, MD

Light-emitting diode photobiomodulation is the newest category of nonthermal light therapies to find its way to the dermatologic armamentarium. In this article, we briefly review the literature on the development of this technology, its evolution within esthetic and medical dermatology, and provide practical and technical considerations for use in various conditions. This article also focuses on the specific cell-signaling pathways involved and how the mechanisms at play can be put to use to treat a variety of cutaneous problems as a stand-alone application and/or complementary treatment modality or as one of the best photodynamic therapy light source.

*For a PDF of the full article, click on the link to the left of this introduction.

Daniel Barolet, MD

Light-emitting diode photobiomodulation is the newest category of nonthermal light therapies to find its way to the dermatologic armamentarium. In this article, we briefly review the literature on the development of this technology, its evolution within esthetic and medical dermatology, and provide practical and technical considerations for use in various conditions. This article also focuses on the specific cell-signaling pathways involved and how the mechanisms at play can be put to use to treat a variety of cutaneous problems as a stand-alone application and/or complementary treatment modality or as one of the best photodynamic therapy light source.

*For a PDF of the full article, click on the link to the left of this introduction.

William F. Groff, DO, FAAD, Richard E. Fitzpatrick, MD, FAAD, and Nathan S. Uebelhoer, DO, FAAD

Photodamage is one of the most common reasons that patients visit a dermatologist’s office. Carbon dioxide (CO2) laser resurfacing has always been the gold standard for reversing photodamage. Because of the relatively high incidence of side effects and the prolonged downtime associated with CO2 resurfacing, new technologies have emerged to address photodamage. Portrait skin regeneration (PSR) is a novel device that has been developed to treat photodamage, and this device yields fewer side effects and downtime than traditional CO2 laser resurfacing. At our center, we have performed more than 500 high-energy PSR treatments and have developed a unique and highly effective treatment protocol. In addition, fractional CO2 laser resurfacing has emerged as the latest technology developed to combat photoaging. This technology yields impressive results and is much safer and causes less downtime than traditional CO2 laser resurfacing. In this article, we will review our treatment techniques and protocols as well as address patient selection, preoperative and postoperative care, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

William F. Groff, DO, FAAD, Richard E. Fitzpatrick, MD, FAAD, and Nathan S. Uebelhoer, DO, FAAD

Photodamage is one of the most common reasons that patients visit a dermatologist’s office. Carbon dioxide (CO2) laser resurfacing has always been the gold standard for reversing photodamage. Because of the relatively high incidence of side effects and the prolonged downtime associated with CO2 resurfacing, new technologies have emerged to address photodamage. Portrait skin regeneration (PSR) is a novel device that has been developed to treat photodamage, and this device yields fewer side effects and downtime than traditional CO2 laser resurfacing. At our center, we have performed more than 500 high-energy PSR treatments and have developed a unique and highly effective treatment protocol. In addition, fractional CO2 laser resurfacing has emerged as the latest technology developed to combat photoaging. This technology yields impressive results and is much safer and causes less downtime than traditional CO2 laser resurfacing. In this article, we will review our treatment techniques and protocols as well as address patient selection, preoperative and postoperative care, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

William F. Groff, DO, FAAD, Richard E. Fitzpatrick, MD, FAAD, and Nathan S. Uebelhoer, DO, FAAD

Photodamage is one of the most common reasons that patients visit a dermatologist’s office. Carbon dioxide (CO2) laser resurfacing has always been the gold standard for reversing photodamage. Because of the relatively high incidence of side effects and the prolonged downtime associated with CO2 resurfacing, new technologies have emerged to address photodamage. Portrait skin regeneration (PSR) is a novel device that has been developed to treat photodamage, and this device yields fewer side effects and downtime than traditional CO2 laser resurfacing. At our center, we have performed more than 500 high-energy PSR treatments and have developed a unique and highly effective treatment protocol. In addition, fractional CO2 laser resurfacing has emerged as the latest technology developed to combat photoaging. This technology yields impressive results and is much safer and causes less downtime than traditional CO2 laser resurfacing. In this article, we will review our treatment techniques and protocols as well as address patient selection, preoperative and postoperative care, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

Melissa A. Bogle, MD

Fractional resurfacing devices thermally alter microscopic treatment columns in the skin, leaving intervening areas between the columns untouched. Because only a fraction of the skin is being modified, untreated areas are able to rapidly repopulate the treatment columns to greatly reduce recovery time and adverse events. Mid-infrared fractional systems have shown improvement in treating photoaging, scars, rhytides, dyschromia, and textural disorders. An additional advantage is that they are safe and effective for the treatment of nonfacial areas such as the neck, chest, and extremities.

*For a PDF of the full article, click on the link to the left of this introduction.

Melissa A. Bogle, MD

Fractional resurfacing devices thermally alter microscopic treatment columns in the skin, leaving intervening areas between the columns untouched. Because only a fraction of the skin is being modified, untreated areas are able to rapidly repopulate the treatment columns to greatly reduce recovery time and adverse events. Mid-infrared fractional systems have shown improvement in treating photoaging, scars, rhytides, dyschromia, and textural disorders. An additional advantage is that they are safe and effective for the treatment of nonfacial areas such as the neck, chest, and extremities.

*For a PDF of the full article, click on the link to the left of this introduction.

Melissa A. Bogle, MD

Fractional resurfacing devices thermally alter microscopic treatment columns in the skin, leaving intervening areas between the columns untouched. Because only a fraction of the skin is being modified, untreated areas are able to rapidly repopulate the treatment columns to greatly reduce recovery time and adverse events. Mid-infrared fractional systems have shown improvement in treating photoaging, scars, rhytides, dyschromia, and textural disorders. An additional advantage is that they are safe and effective for the treatment of nonfacial areas such as the neck, chest, and extremities.

*For a PDF of the full article, click on the link to the left of this introduction.

Eric C. Parlette, MD and Michael E. Kaminer, MD

Liposuction is one of the most popular cosmetic procedures. The advent of laser-assisted liposuction is the next evolutionary step in the market of body contouring. The goal of laser-assisted liposuction is to facilitate liposuctioning, enhance tissue tightening, and reduce downtime and morbidity. Several different protocols using different devices and wavelengths generate variable results. Current laser-assisted lipolysis technology and techniques are reviewed with respective expectations. As laser lipolysis technology and coinciding experience grow, so will the ability to achieve the aims of more efficient, safer, and cosmetically pleasing body sculpting.

*For a PDF of the full article, click on the link to the left of this introduction.

Eric C. Parlette, MD and Michael E. Kaminer, MD

Liposuction is one of the most popular cosmetic procedures. The advent of laser-assisted liposuction is the next evolutionary step in the market of body contouring. The goal of laser-assisted liposuction is to facilitate liposuctioning, enhance tissue tightening, and reduce downtime and morbidity. Several different protocols using different devices and wavelengths generate variable results. Current laser-assisted lipolysis technology and techniques are reviewed with respective expectations. As laser lipolysis technology and coinciding experience grow, so will the ability to achieve the aims of more efficient, safer, and cosmetically pleasing body sculpting.

*For a PDF of the full article, click on the link to the left of this introduction.

Eric C. Parlette, MD and Michael E. Kaminer, MD

Liposuction is one of the most popular cosmetic procedures. The advent of laser-assisted liposuction is the next evolutionary step in the market of body contouring. The goal of laser-assisted liposuction is to facilitate liposuctioning, enhance tissue tightening, and reduce downtime and morbidity. Several different protocols using different devices and wavelengths generate variable results. Current laser-assisted lipolysis technology and techniques are reviewed with respective expectations. As laser lipolysis technology and coinciding experience grow, so will the ability to achieve the aims of more efficient, safer, and cosmetically pleasing body sculpting.

*For a PDF of the full article, click on the link to the left of this introduction.

Natasha Brasic, MD, David Lopresti, MD, and Hugh McSwain, MD

Superficial venous insufficiency is a common problem associated with varicose veins. Venous insufficiency and varicose veins can be symptomatic, but more commonly they are a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology of superficial venous insufficiency, review the current literature for varicose vein treatment, and cover the technical aspects of diagnosing and treating superficial venous insufficiency. Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the most common cause of varicose veins; because this condition constitutes the majority of patients encountered in practice, we will concentrate on this area. Endovenous laser ablation and sclerotherapy are covered, including patient workup and selection, procedure set-up, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

Natasha Brasic, MD, David Lopresti, MD, and Hugh McSwain, MD

Superficial venous insufficiency is a common problem associated with varicose veins. Venous insufficiency and varicose veins can be symptomatic, but more commonly they are a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology of superficial venous insufficiency, review the current literature for varicose vein treatment, and cover the technical aspects of diagnosing and treating superficial venous insufficiency. Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the most common cause of varicose veins; because this condition constitutes the majority of patients encountered in practice, we will concentrate on this area. Endovenous laser ablation and sclerotherapy are covered, including patient workup and selection, procedure set-up, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

Natasha Brasic, MD, David Lopresti, MD, and Hugh McSwain, MD

Superficial venous insufficiency is a common problem associated with varicose veins. Venous insufficiency and varicose veins can be symptomatic, but more commonly they are a cosmetic concern. In this article, we discuss the relevant anatomy and pathophysiology of superficial venous insufficiency, review the current literature for varicose vein treatment, and cover the technical aspects of diagnosing and treating superficial venous insufficiency. Saphenofemoral junction incompetence with resultant greater saphenous vein reflux is the most common cause of varicose veins; because this condition constitutes the majority of patients encountered in practice, we will concentrate on this area. Endovenous laser ablation and sclerotherapy are covered, including patient workup and selection, procedure set-up, and anesthesia.

*For a PDF of the full article, click on the link to the left of this introduction.

Kenneth J. Galeckas, MD

Patients frequently present to dermatologists for the treatment of vascular lesions, including facial telangiectases, diffuse redness, port wine stains (PWS), hemangiomas, and leg veins. There are many laser and light devices that can be used with excellent results. This article summarizes the available platforms that are commonly used for the treatment of superficial vascular lesions. Newer devices and techniques are highlighted with respect to the unique characteristics of individual lesions.

*For a PDF of the full article, click on the link to the left of this introduction.

Kenneth J. Galeckas, MD

Patients frequently present to dermatologists for the treatment of vascular lesions, including facial telangiectases, diffuse redness, port wine stains (PWS), hemangiomas, and leg veins. There are many laser and light devices that can be used with excellent results. This article summarizes the available platforms that are commonly used for the treatment of superficial vascular lesions. Newer devices and techniques are highlighted with respect to the unique characteristics of individual lesions.

*For a PDF of the full article, click on the link to the left of this introduction.

Kenneth J. Galeckas, MD

Patients frequently present to dermatologists for the treatment of vascular lesions, including facial telangiectases, diffuse redness, port wine stains (PWS), hemangiomas, and leg veins. There are many laser and light devices that can be used with excellent results. This article summarizes the available platforms that are commonly used for the treatment of superficial vascular lesions. Newer devices and techniques are highlighted with respect to the unique characteristics of individual lesions.

*For a PDF of the full article, click on the link to the left of this introduction.

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.

Divya Railan, MD, and Tina S. Alster, MD

Lasers frequently are used by dermatologists for their multiple aesthetic applications, but they also can be used to treat a variety of medical dermatology conditions. Conditions such as acne vulgaris, psoriasis, and vitiligo can all be successfully treated with laser, thereby providing the patient with additional therapeutic options. Lasers have also been used for years to improve the appearance of scars. The newer fractionated lasers have been especially effective in enhancing the clinical outcomes of scar revision.

*For a PDF of the full article, click on the link to the left of this introduction.