Aesthetic Dermatology

KISSIMMEE, FLA. — Treatment with a fixed array fractional 1540-nm erbium laser was effective for improving acne scars, a review of 181 patients found.

At 3-month follow-up, the patients who underwent three treatments at 4-week intervals with the Lux1540 laser (Palomar Medical Technologies Inc., Burlington, Mass.) had a median improvement of 3 by Canfield blinded photographic evaluation (Canfield Scientific Inc. Omnia system), which translates to a 50%-75% improvement in scar appearance, Dr. Robert A. Weiss reported at the annual meeting of the American Society of Laser Medicine and Surgery.

Treatments were given using the 10-mm, 100-microbeam per pulse handpiece for a minimum of three passes per treatment site at 10-millisecond pulse duration. Fluence was set at 50–70 mJ/microbeam, said Dr. Weiss of the Maryland Laser, Skin, and Vein Institute, Baltimore.

Self-assessed treatment results indicated that the patients were pleased with the outcomes, with 85% rating their skin as improved. Patient self-assessment indicated that pain was minimal, with a reported average pain score of 2.75 out of 10.

Side effects were minimal and included mild erythema and edema, which resolved in all patients within 24 hours.

The findings suggest that a minimal fluence of 50 mJ/microbeam with three passes is required to achieve improvement in acne scars with this laser, Dr. Weiss noted.

The study was supported by Palomar, which provided Dr. Weiss with equipment, discounts, a research grant, and honoraria.

KISSIMMEE, FLA. — Treatment with a fixed array fractional 1540-nm erbium laser was effective for improving acne scars, a review of 181 patients found.

At 3-month follow-up, the patients who underwent three treatments at 4-week intervals with the Lux1540 laser (Palomar Medical Technologies Inc., Burlington, Mass.) had a median improvement of 3 by Canfield blinded photographic evaluation (Canfield Scientific Inc. Omnia system), which translates to a 50%-75% improvement in scar appearance, Dr. Robert A. Weiss reported at the annual meeting of the American Society of Laser Medicine and Surgery.

Treatments were given using the 10-mm, 100-microbeam per pulse handpiece for a minimum of three passes per treatment site at 10-millisecond pulse duration. Fluence was set at 50–70 mJ/microbeam, said Dr. Weiss of the Maryland Laser, Skin, and Vein Institute, Baltimore.

Self-assessed treatment results indicated that the patients were pleased with the outcomes, with 85% rating their skin as improved. Patient self-assessment indicated that pain was minimal, with a reported average pain score of 2.75 out of 10.

Side effects were minimal and included mild erythema and edema, which resolved in all patients within 24 hours.

The findings suggest that a minimal fluence of 50 mJ/microbeam with three passes is required to achieve improvement in acne scars with this laser, Dr. Weiss noted.

The study was supported by Palomar, which provided Dr. Weiss with equipment, discounts, a research grant, and honoraria.

KISSIMMEE, FLA. — Treatment with a fixed array fractional 1540-nm erbium laser was effective for improving acne scars, a review of 181 patients found.

At 3-month follow-up, the patients who underwent three treatments at 4-week intervals with the Lux1540 laser (Palomar Medical Technologies Inc., Burlington, Mass.) had a median improvement of 3 by Canfield blinded photographic evaluation (Canfield Scientific Inc. Omnia system), which translates to a 50%-75% improvement in scar appearance, Dr. Robert A. Weiss reported at the annual meeting of the American Society of Laser Medicine and Surgery.

Treatments were given using the 10-mm, 100-microbeam per pulse handpiece for a minimum of three passes per treatment site at 10-millisecond pulse duration. Fluence was set at 50–70 mJ/microbeam, said Dr. Weiss of the Maryland Laser, Skin, and Vein Institute, Baltimore.

Self-assessed treatment results indicated that the patients were pleased with the outcomes, with 85% rating their skin as improved. Patient self-assessment indicated that pain was minimal, with a reported average pain score of 2.75 out of 10.

Side effects were minimal and included mild erythema and edema, which resolved in all patients within 24 hours.

The findings suggest that a minimal fluence of 50 mJ/microbeam with three passes is required to achieve improvement in acne scars with this laser, Dr. Weiss noted.

The study was supported by Palomar, which provided Dr. Weiss with equipment, discounts, a research grant, and honoraria.

KISSIMMEE, FLA. — Fractional photothermolysis is a promising treatment for surgical scars, including those that have failed to fully respond to other treatments, a small study suggests.

In 13 patients with various types and ages of surgical scars, fractional resurfacing using Reliant Technologies Inc.'s 1,550-nm, erbium-doped fiber laser (Fraxel) resulted in greater than 75% improvement in nine patients and at least 51%-75% improvement in an additional two patients.

The remaining two patients achieved between 25% and 50% improvement, Dr. Joy Kunishige reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients were treated for scars resulting from Mohs surgery, excision, trauma, or plastic surgery, and most underwent a total of three treatments (range, two to eight). Treatments were administered at energy levels of 6–70 mJ, with final densities of 312–2,500 microthermal zones per square centimeter.

Outcomes were based on physician assessment of photographs that were taken at baseline and at 2 weeks following final treatment.

"All the characteristics that we looked at improved, including atrophy, hypertrophy, hyperpigmentation, and erythema," said Dr. Kunishige of the University of Texas Health Sciences Center, Houston, noting that all outcomes scores were maintained at the 12-month follow-up.

Traditional scar treatment involves use of the pulsed dye laser, but it appears that fractional resurfacing may provide better depth of penetration, she said. "Admittedly, many of the scars were new, and were possibly still undergoing remodeling, but even older scars showed similar improvement."

Scars that had failed to respond fully to prior therapies also responded to the Fraxel laser. It appears that this laser can be used as monotherapy for treating scars, or as an adjunct to other treatments, she said.

Dr. Kunishige reported no financial conflicts related to her presentation.

KISSIMMEE, FLA. — Fractional photothermolysis is a promising treatment for surgical scars, including those that have failed to fully respond to other treatments, a small study suggests.

In 13 patients with various types and ages of surgical scars, fractional resurfacing using Reliant Technologies Inc.'s 1,550-nm, erbium-doped fiber laser (Fraxel) resulted in greater than 75% improvement in nine patients and at least 51%-75% improvement in an additional two patients.

The remaining two patients achieved between 25% and 50% improvement, Dr. Joy Kunishige reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients were treated for scars resulting from Mohs surgery, excision, trauma, or plastic surgery, and most underwent a total of three treatments (range, two to eight). Treatments were administered at energy levels of 6–70 mJ, with final densities of 312–2,500 microthermal zones per square centimeter.

Outcomes were based on physician assessment of photographs that were taken at baseline and at 2 weeks following final treatment.

"All the characteristics that we looked at improved, including atrophy, hypertrophy, hyperpigmentation, and erythema," said Dr. Kunishige of the University of Texas Health Sciences Center, Houston, noting that all outcomes scores were maintained at the 12-month follow-up.

Traditional scar treatment involves use of the pulsed dye laser, but it appears that fractional resurfacing may provide better depth of penetration, she said. "Admittedly, many of the scars were new, and were possibly still undergoing remodeling, but even older scars showed similar improvement."

Scars that had failed to respond fully to prior therapies also responded to the Fraxel laser. It appears that this laser can be used as monotherapy for treating scars, or as an adjunct to other treatments, she said.

Dr. Kunishige reported no financial conflicts related to her presentation.

KISSIMMEE, FLA. — Fractional photothermolysis is a promising treatment for surgical scars, including those that have failed to fully respond to other treatments, a small study suggests.

In 13 patients with various types and ages of surgical scars, fractional resurfacing using Reliant Technologies Inc.'s 1,550-nm, erbium-doped fiber laser (Fraxel) resulted in greater than 75% improvement in nine patients and at least 51%-75% improvement in an additional two patients.

The remaining two patients achieved between 25% and 50% improvement, Dr. Joy Kunishige reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients were treated for scars resulting from Mohs surgery, excision, trauma, or plastic surgery, and most underwent a total of three treatments (range, two to eight). Treatments were administered at energy levels of 6–70 mJ, with final densities of 312–2,500 microthermal zones per square centimeter.

Outcomes were based on physician assessment of photographs that were taken at baseline and at 2 weeks following final treatment.

"All the characteristics that we looked at improved, including atrophy, hypertrophy, hyperpigmentation, and erythema," said Dr. Kunishige of the University of Texas Health Sciences Center, Houston, noting that all outcomes scores were maintained at the 12-month follow-up.

Traditional scar treatment involves use of the pulsed dye laser, but it appears that fractional resurfacing may provide better depth of penetration, she said. "Admittedly, many of the scars were new, and were possibly still undergoing remodeling, but even older scars showed similar improvement."

Scars that had failed to respond fully to prior therapies also responded to the Fraxel laser. It appears that this laser can be used as monotherapy for treating scars, or as an adjunct to other treatments, she said.

Dr. Kunishige reported no financial conflicts related to her presentation.

KISSIMMEE, FLA. — Combined radiofrequency energy and indocyanine green-mediated pulsed light phototherapy proved highly effective for the treatment of acne in a study of 14 Fitzpatrick skin type IV patients with substantial facial acne.

The patients, who were aged 16–35 years (mean age 25 years), and who had at least 10 inflamed facial acne lesions, were treated with 1 mg/mL indocyanine green (ICG) cream, which was applied to the face for 30 minutes and then wiped off. This was followed by combination pulsed light at 580–980 nm, and a radiofrequency device, Syneron Medical Ltd.'s Aurora SR, at an optical energy of 18–22 J/cm

The patients, who received no topical or oral acne medications in the 2 months prior to study initiation, received three treatments at 4-week intervals. Lesion count decreased by 18%, 49%, 68%, and 76%, at 4, 8, 12, and 16 weeks, respectively, after the initial treatment, said Dr. Rho of the Leaders Clinic in Seoul, South Korea.

Follow-up at 1, 4, 7, and 14 days after each treatment showed that side effects were minimal, and included only transient stinging and slight peeling, said Dr. Rho, who reported that he had no financial disclosures associated with his presentation.

ICG-mediated near-infrared light phototherapy has received a great deal of attention for the treatment of acne because of its sebaceous gland selectivity and high penetration depth. In addition, radiofrequency energy is known to reduce sebum production. Together, these treatments can substantially reduce the number of acne lesions, he said.

A 31-year-old female patient is shown before treatment (top). Improvement is seen after one session (bottom). Photos courtesy Dr. Nark-Kyoung Rho

ELSEVIER GLOBAL MEDICAL NEWS

KISSIMMEE, FLA. — Combined radiofrequency energy and indocyanine green-mediated pulsed light phototherapy proved highly effective for the treatment of acne in a study of 14 Fitzpatrick skin type IV patients with substantial facial acne.

The patients, who were aged 16–35 years (mean age 25 years), and who had at least 10 inflamed facial acne lesions, were treated with 1 mg/mL indocyanine green (ICG) cream, which was applied to the face for 30 minutes and then wiped off. This was followed by combination pulsed light at 580–980 nm, and a radiofrequency device, Syneron Medical Ltd.'s Aurora SR, at an optical energy of 18–22 J/cm

The patients, who received no topical or oral acne medications in the 2 months prior to study initiation, received three treatments at 4-week intervals. Lesion count decreased by 18%, 49%, 68%, and 76%, at 4, 8, 12, and 16 weeks, respectively, after the initial treatment, said Dr. Rho of the Leaders Clinic in Seoul, South Korea.

Follow-up at 1, 4, 7, and 14 days after each treatment showed that side effects were minimal, and included only transient stinging and slight peeling, said Dr. Rho, who reported that he had no financial disclosures associated with his presentation.

ICG-mediated near-infrared light phototherapy has received a great deal of attention for the treatment of acne because of its sebaceous gland selectivity and high penetration depth. In addition, radiofrequency energy is known to reduce sebum production. Together, these treatments can substantially reduce the number of acne lesions, he said.

A 31-year-old female patient is shown before treatment (top). Improvement is seen after one session (bottom). Photos courtesy Dr. Nark-Kyoung Rho

ELSEVIER GLOBAL MEDICAL NEWS

KISSIMMEE, FLA. — Combined radiofrequency energy and indocyanine green-mediated pulsed light phototherapy proved highly effective for the treatment of acne in a study of 14 Fitzpatrick skin type IV patients with substantial facial acne.

The patients, who were aged 16–35 years (mean age 25 years), and who had at least 10 inflamed facial acne lesions, were treated with 1 mg/mL indocyanine green (ICG) cream, which was applied to the face for 30 minutes and then wiped off. This was followed by combination pulsed light at 580–980 nm, and a radiofrequency device, Syneron Medical Ltd.'s Aurora SR, at an optical energy of 18–22 J/cm

The patients, who received no topical or oral acne medications in the 2 months prior to study initiation, received three treatments at 4-week intervals. Lesion count decreased by 18%, 49%, 68%, and 76%, at 4, 8, 12, and 16 weeks, respectively, after the initial treatment, said Dr. Rho of the Leaders Clinic in Seoul, South Korea.

Follow-up at 1, 4, 7, and 14 days after each treatment showed that side effects were minimal, and included only transient stinging and slight peeling, said Dr. Rho, who reported that he had no financial disclosures associated with his presentation.

ICG-mediated near-infrared light phototherapy has received a great deal of attention for the treatment of acne because of its sebaceous gland selectivity and high penetration depth. In addition, radiofrequency energy is known to reduce sebum production. Together, these treatments can substantially reduce the number of acne lesions, he said.

A 31-year-old female patient is shown before treatment (top). Improvement is seen after one session (bottom). Photos courtesy Dr. Nark-Kyoung Rho

ELSEVIER GLOBAL MEDICAL NEWS

KISSIMMEE, FLA. — Focal radiofrequency ablation of the neural innervation of the glabella muscle complex provided an effective and possibly more durable alternative to botulinum toxin in a series of 10 patients with concerns about glabellar frown lines.

The procedure, which is known as glabellar frown relaxation (GFX) radiofrequency ablation, was approved by the Food and Drug Administration for tissue ablation last year and has been touted as a new and improved means of relaxing frown lines without the use of toxins.

Of the 10 patients who underwent the treatment, 6 had an immediate complete response and 4 had partial attenuation of their frown lines, as judged by the inability to frown, said Dr. Cameron Rokhsar of Albert Einstein College of Medicine, New York.

Additionally, medial brow elevation occurred in five of the patients, he noted at the annual meeting of the American Society for Laser Medicine and Surgery.

The effects remained apparent at 3-month follow-up.

All patients tolerated the procedure; side effects were limited to bruising and moderate pain during treatment.

The GFX radiofrequency ablation procedure, which is performed under local anesthesia, involves insertion of a probe at the lateral canthi on each side and the use of mild electrostimulation to identify the rami of the temporal branch of the facial nerve innervating the corrugators.

A 20-second radiofrequency pulse is applied to cause the focal nerve injury, and the probe is then advanced on the nasal sidewall to identify and ablate the branches of the angular nerve innervating the procerus.

Although both botulinum toxin and GFX radiofrequency ablation target the nerves that cause frown lines, botulinum toxin therapies block signals sent from the nerves to the muscles while GFX radiofrequency energy is used to create focal damage to effectively weaken the motor nerves, Dr. Rokhsar explained.

As a result, the duration of effect is increased with GFX radiofrequency; some reports suggest that the duration can be up to 2 years, compared with 3–4 months for botulinum toxin treatments. Studies to review long-term efficacy are underway, he said, adding that "the procedure has a learning curve."

KISSIMMEE, FLA. — Focal radiofrequency ablation of the neural innervation of the glabella muscle complex provided an effective and possibly more durable alternative to botulinum toxin in a series of 10 patients with concerns about glabellar frown lines.

The procedure, which is known as glabellar frown relaxation (GFX) radiofrequency ablation, was approved by the Food and Drug Administration for tissue ablation last year and has been touted as a new and improved means of relaxing frown lines without the use of toxins.

Of the 10 patients who underwent the treatment, 6 had an immediate complete response and 4 had partial attenuation of their frown lines, as judged by the inability to frown, said Dr. Cameron Rokhsar of Albert Einstein College of Medicine, New York.

Additionally, medial brow elevation occurred in five of the patients, he noted at the annual meeting of the American Society for Laser Medicine and Surgery.

The effects remained apparent at 3-month follow-up.

All patients tolerated the procedure; side effects were limited to bruising and moderate pain during treatment.

The GFX radiofrequency ablation procedure, which is performed under local anesthesia, involves insertion of a probe at the lateral canthi on each side and the use of mild electrostimulation to identify the rami of the temporal branch of the facial nerve innervating the corrugators.

A 20-second radiofrequency pulse is applied to cause the focal nerve injury, and the probe is then advanced on the nasal sidewall to identify and ablate the branches of the angular nerve innervating the procerus.

Although both botulinum toxin and GFX radiofrequency ablation target the nerves that cause frown lines, botulinum toxin therapies block signals sent from the nerves to the muscles while GFX radiofrequency energy is used to create focal damage to effectively weaken the motor nerves, Dr. Rokhsar explained.

As a result, the duration of effect is increased with GFX radiofrequency; some reports suggest that the duration can be up to 2 years, compared with 3–4 months for botulinum toxin treatments. Studies to review long-term efficacy are underway, he said, adding that "the procedure has a learning curve."

KISSIMMEE, FLA. — Focal radiofrequency ablation of the neural innervation of the glabella muscle complex provided an effective and possibly more durable alternative to botulinum toxin in a series of 10 patients with concerns about glabellar frown lines.

The procedure, which is known as glabellar frown relaxation (GFX) radiofrequency ablation, was approved by the Food and Drug Administration for tissue ablation last year and has been touted as a new and improved means of relaxing frown lines without the use of toxins.

Of the 10 patients who underwent the treatment, 6 had an immediate complete response and 4 had partial attenuation of their frown lines, as judged by the inability to frown, said Dr. Cameron Rokhsar of Albert Einstein College of Medicine, New York.

Additionally, medial brow elevation occurred in five of the patients, he noted at the annual meeting of the American Society for Laser Medicine and Surgery.

The effects remained apparent at 3-month follow-up.

All patients tolerated the procedure; side effects were limited to bruising and moderate pain during treatment.

The GFX radiofrequency ablation procedure, which is performed under local anesthesia, involves insertion of a probe at the lateral canthi on each side and the use of mild electrostimulation to identify the rami of the temporal branch of the facial nerve innervating the corrugators.

A 20-second radiofrequency pulse is applied to cause the focal nerve injury, and the probe is then advanced on the nasal sidewall to identify and ablate the branches of the angular nerve innervating the procerus.

Although both botulinum toxin and GFX radiofrequency ablation target the nerves that cause frown lines, botulinum toxin therapies block signals sent from the nerves to the muscles while GFX radiofrequency energy is used to create focal damage to effectively weaken the motor nerves, Dr. Rokhsar explained.

As a result, the duration of effect is increased with GFX radiofrequency; some reports suggest that the duration can be up to 2 years, compared with 3–4 months for botulinum toxin treatments. Studies to review long-term efficacy are underway, he said, adding that "the procedure has a learning curve."

KISSIMMEE, FLA. — A single treatment with a microfractional 2940-nm erbium:YAG laser resulted in perioral wrinkle reduction of greater than 40% and an improvement of 2–3 grades on the Fitzpatrick wrinkle assessment scale in a recent study.

In all, 23 patients with a score of 5–9 on the 9-point Fitzpatrick scale underwent full-face laser treatment. The improvements from baseline were noted after the first treatment, Dr. E. Victor Ross reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients, who had skin types ranging from I to III, were treated with a 6- to 10-mm spot size and energy ranging from 400 to 920 microbeams/cm

Between one and three passes were used in less photodamaged areas, and three to eight passes were used in more severely damaged areas. Additionally, small areas were treated with a traditional short-pulse erbium:YAG laser at four passes and 5 J/cm

Preliminary findings suggest that the microfractional erbium:YAG treatments resulted in a similar wrinkle response to that observed with traditional short-pulse erbium:YAG laser treatments; however, healing times were reduced with the microfractional erbium:YAG, said Dr. Ross of the Scripps Clinic in San Diego.

Dr. Ross acknowledged that he has received equipment, consulting fees, and a research grant from Palomar Medical Technologies Inc.

"There was very rapid recovery, both histologically and clinically," he said, noting that the average full-face treatment time was 48 minutes. Re-epithelialization of the basal layer of the epidermis occurred within 12–24 hours, and complete re-epithelialization occurred within 4–5 days.

Bronzed skin was noted immediately after the treatments, and some patients experienced focal pinpoint hemorrhage. At 2 weeks, however, only mild erythema remained, he said.

On microscopic examination, separated columns of ablation were noted, typically with a depth of 200 microns and 20–30 microns of residual thermal damage at the periphery of the conical microwounds.

Not only did the treatment lead to smoothing of the skin and reduction of perioral wrinkles, but improvements in dyschromia were also noted, Dr. Ross said.

Although optimal treatment parameters for wrinkle reduction remain to be defined, these findings suggest that microfractional 2940-nm laser treatment is superior to traditional short-pulse erbium:YAG laser treatment for this purpose, he concluded.

KISSIMMEE, FLA. — A single treatment with a microfractional 2940-nm erbium:YAG laser resulted in perioral wrinkle reduction of greater than 40% and an improvement of 2–3 grades on the Fitzpatrick wrinkle assessment scale in a recent study.

In all, 23 patients with a score of 5–9 on the 9-point Fitzpatrick scale underwent full-face laser treatment. The improvements from baseline were noted after the first treatment, Dr. E. Victor Ross reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients, who had skin types ranging from I to III, were treated with a 6- to 10-mm spot size and energy ranging from 400 to 920 microbeams/cm

Between one and three passes were used in less photodamaged areas, and three to eight passes were used in more severely damaged areas. Additionally, small areas were treated with a traditional short-pulse erbium:YAG laser at four passes and 5 J/cm

Preliminary findings suggest that the microfractional erbium:YAG treatments resulted in a similar wrinkle response to that observed with traditional short-pulse erbium:YAG laser treatments; however, healing times were reduced with the microfractional erbium:YAG, said Dr. Ross of the Scripps Clinic in San Diego.

Dr. Ross acknowledged that he has received equipment, consulting fees, and a research grant from Palomar Medical Technologies Inc.

"There was very rapid recovery, both histologically and clinically," he said, noting that the average full-face treatment time was 48 minutes. Re-epithelialization of the basal layer of the epidermis occurred within 12–24 hours, and complete re-epithelialization occurred within 4–5 days.

Bronzed skin was noted immediately after the treatments, and some patients experienced focal pinpoint hemorrhage. At 2 weeks, however, only mild erythema remained, he said.

On microscopic examination, separated columns of ablation were noted, typically with a depth of 200 microns and 20–30 microns of residual thermal damage at the periphery of the conical microwounds.

Not only did the treatment lead to smoothing of the skin and reduction of perioral wrinkles, but improvements in dyschromia were also noted, Dr. Ross said.

Although optimal treatment parameters for wrinkle reduction remain to be defined, these findings suggest that microfractional 2940-nm laser treatment is superior to traditional short-pulse erbium:YAG laser treatment for this purpose, he concluded.

KISSIMMEE, FLA. — A single treatment with a microfractional 2940-nm erbium:YAG laser resulted in perioral wrinkle reduction of greater than 40% and an improvement of 2–3 grades on the Fitzpatrick wrinkle assessment scale in a recent study.

In all, 23 patients with a score of 5–9 on the 9-point Fitzpatrick scale underwent full-face laser treatment. The improvements from baseline were noted after the first treatment, Dr. E. Victor Ross reported at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients, who had skin types ranging from I to III, were treated with a 6- to 10-mm spot size and energy ranging from 400 to 920 microbeams/cm

Between one and three passes were used in less photodamaged areas, and three to eight passes were used in more severely damaged areas. Additionally, small areas were treated with a traditional short-pulse erbium:YAG laser at four passes and 5 J/cm

Preliminary findings suggest that the microfractional erbium:YAG treatments resulted in a similar wrinkle response to that observed with traditional short-pulse erbium:YAG laser treatments; however, healing times were reduced with the microfractional erbium:YAG, said Dr. Ross of the Scripps Clinic in San Diego.

Dr. Ross acknowledged that he has received equipment, consulting fees, and a research grant from Palomar Medical Technologies Inc.

"There was very rapid recovery, both histologically and clinically," he said, noting that the average full-face treatment time was 48 minutes. Re-epithelialization of the basal layer of the epidermis occurred within 12–24 hours, and complete re-epithelialization occurred within 4–5 days.

Bronzed skin was noted immediately after the treatments, and some patients experienced focal pinpoint hemorrhage. At 2 weeks, however, only mild erythema remained, he said.

On microscopic examination, separated columns of ablation were noted, typically with a depth of 200 microns and 20–30 microns of residual thermal damage at the periphery of the conical microwounds.

Not only did the treatment lead to smoothing of the skin and reduction of perioral wrinkles, but improvements in dyschromia were also noted, Dr. Ross said.

Although optimal treatment parameters for wrinkle reduction remain to be defined, these findings suggest that microfractional 2940-nm laser treatment is superior to traditional short-pulse erbium:YAG laser treatment for this purpose, he concluded.

KISSIMMEE, FLA. — The 1,064-nm neodymium:YAG laser is effective for treating and preventing the recurrence of hidradenitis suppurativa lesions, according to the results of a randomized, controlled study of 22 patients with the disease.

The 1,064-nm Nd:YAG laser is commonly used for laser hair removal but also seems well suited for treating hidradenitis suppurativa, which histologic studies suggest is a disease of follicular occlusion with apocrine gland involvement as a secondary event, according to Dr. Emily P. Tierney and her colleagues in the department of dermatology at Henry Ford Hospital, Detroit.

Despite the fact that medical treatments for hidradenitis suppurativa have had limited efficacy against the disease and surgical treatment is associated with high morbidity, an initial pilot study conducted by Dr. Tierney and her associates found the laser to be efficacious in treating the disease.

One of Dr. Tierney's coinvestigators in Henry Ford's dermatology department, Dr. Iltefat Hamzavi, previously conducted a study of the Nd:YAG laser in four patients with dissecting cellulitis, a disorder analogous to hidradenitis suppurativa. In that study, 1 year after the initiation of laser treatment, patients achieved decreased pus formation, a reduced reliance on systemic treatments, and a controlled or terminated disease process without dyspigmentation (Dermatol. Surg. 2006;32:1039–44).

In a poster presentation at the annual meeting of the American Society for Laser Medicine and Surgery, Dr. Tierney and her coinvestigators reported on the effect of the laser on 22 patients with bilateral and symmetrical disease who were randomized to receive laser treatment plus topical antibiotics at affected sites on one side of the body and only topical antibiotics on affected sites on the contralateral side.

The patients had a mean age of 41 years, and 15 of them had Hurley stage II hidradenitis suppurativa, which is characterized by recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. The other seven patients had stage III disease, which is exemplified by diffuse or near diffuse involvement, or multiple interconnected tracts and abscesses across the entire area.

Half of the 22 patients had Fitzpatrick skin type III, followed by 4 patients with type V, 3 with type IV, 3 with type II, and 1 with type VI.

After a series of up to four laser treatment sessions conducted once per month, there was a significant improvement in clinical scoring criteria based on a modified Hidradenitis Suppurativa European Research Group (HISERG) scale at all three anatomical sites treated with the laser (groin, axilla, and inframammary sites).

Compared with control sites, laser treatment improved the modified HISERG scale by the greatest amount for inguinal lesions (68% vs. 2%). Laser treatment also significantly improved HISERG scale scores of lesions in the axilla (63% vs. −11%) and at inframammary sites (30% vs. −71%).

Dr. Tierney reported that their research was supported by a Cutting Edge Research Grant from the American Society for Dermatologic Surgery and the Shahani Fund, a private individual donor that supports research at Henry Ford Hospital. Neither Dr. Tierney nor Dr. Hamzavi had any conflicts of interest to disclose.

At 2 months after the end of treatment, the patients continued to have significantly better modified HISERG scale scores at all sites combined, compared with all control sites combined.

The differences in response to laser treatment among anatomical sites appeared to be driven by the properties and distribution of hair at the site (density, volume, thickness, and proportion of follicles in anagen phase), according to the investigators.

The inguinal lesions of a patient with a 15-year history of disease are shown.

Lesion improvement is seen 2 months after four monthly laser treatments. Photos courtesy Dr. Emily P. Tierney

KISSIMMEE, FLA. — The 1,064-nm neodymium:YAG laser is effective for treating and preventing the recurrence of hidradenitis suppurativa lesions, according to the results of a randomized, controlled study of 22 patients with the disease.

The 1,064-nm Nd:YAG laser is commonly used for laser hair removal but also seems well suited for treating hidradenitis suppurativa, which histologic studies suggest is a disease of follicular occlusion with apocrine gland involvement as a secondary event, according to Dr. Emily P. Tierney and her colleagues in the department of dermatology at Henry Ford Hospital, Detroit.

Despite the fact that medical treatments for hidradenitis suppurativa have had limited efficacy against the disease and surgical treatment is associated with high morbidity, an initial pilot study conducted by Dr. Tierney and her associates found the laser to be efficacious in treating the disease.

One of Dr. Tierney's coinvestigators in Henry Ford's dermatology department, Dr. Iltefat Hamzavi, previously conducted a study of the Nd:YAG laser in four patients with dissecting cellulitis, a disorder analogous to hidradenitis suppurativa. In that study, 1 year after the initiation of laser treatment, patients achieved decreased pus formation, a reduced reliance on systemic treatments, and a controlled or terminated disease process without dyspigmentation (Dermatol. Surg. 2006;32:1039–44).

In a poster presentation at the annual meeting of the American Society for Laser Medicine and Surgery, Dr. Tierney and her coinvestigators reported on the effect of the laser on 22 patients with bilateral and symmetrical disease who were randomized to receive laser treatment plus topical antibiotics at affected sites on one side of the body and only topical antibiotics on affected sites on the contralateral side.

The patients had a mean age of 41 years, and 15 of them had Hurley stage II hidradenitis suppurativa, which is characterized by recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. The other seven patients had stage III disease, which is exemplified by diffuse or near diffuse involvement, or multiple interconnected tracts and abscesses across the entire area.

Half of the 22 patients had Fitzpatrick skin type III, followed by 4 patients with type V, 3 with type IV, 3 with type II, and 1 with type VI.

After a series of up to four laser treatment sessions conducted once per month, there was a significant improvement in clinical scoring criteria based on a modified Hidradenitis Suppurativa European Research Group (HISERG) scale at all three anatomical sites treated with the laser (groin, axilla, and inframammary sites).

Compared with control sites, laser treatment improved the modified HISERG scale by the greatest amount for inguinal lesions (68% vs. 2%). Laser treatment also significantly improved HISERG scale scores of lesions in the axilla (63% vs. −11%) and at inframammary sites (30% vs. −71%).

Dr. Tierney reported that their research was supported by a Cutting Edge Research Grant from the American Society for Dermatologic Surgery and the Shahani Fund, a private individual donor that supports research at Henry Ford Hospital. Neither Dr. Tierney nor Dr. Hamzavi had any conflicts of interest to disclose.

At 2 months after the end of treatment, the patients continued to have significantly better modified HISERG scale scores at all sites combined, compared with all control sites combined.

The differences in response to laser treatment among anatomical sites appeared to be driven by the properties and distribution of hair at the site (density, volume, thickness, and proportion of follicles in anagen phase), according to the investigators.

The inguinal lesions of a patient with a 15-year history of disease are shown.

Lesion improvement is seen 2 months after four monthly laser treatments. Photos courtesy Dr. Emily P. Tierney

KISSIMMEE, FLA. — The 1,064-nm neodymium:YAG laser is effective for treating and preventing the recurrence of hidradenitis suppurativa lesions, according to the results of a randomized, controlled study of 22 patients with the disease.

The 1,064-nm Nd:YAG laser is commonly used for laser hair removal but also seems well suited for treating hidradenitis suppurativa, which histologic studies suggest is a disease of follicular occlusion with apocrine gland involvement as a secondary event, according to Dr. Emily P. Tierney and her colleagues in the department of dermatology at Henry Ford Hospital, Detroit.

Despite the fact that medical treatments for hidradenitis suppurativa have had limited efficacy against the disease and surgical treatment is associated with high morbidity, an initial pilot study conducted by Dr. Tierney and her associates found the laser to be efficacious in treating the disease.

One of Dr. Tierney's coinvestigators in Henry Ford's dermatology department, Dr. Iltefat Hamzavi, previously conducted a study of the Nd:YAG laser in four patients with dissecting cellulitis, a disorder analogous to hidradenitis suppurativa. In that study, 1 year after the initiation of laser treatment, patients achieved decreased pus formation, a reduced reliance on systemic treatments, and a controlled or terminated disease process without dyspigmentation (Dermatol. Surg. 2006;32:1039–44).

In a poster presentation at the annual meeting of the American Society for Laser Medicine and Surgery, Dr. Tierney and her coinvestigators reported on the effect of the laser on 22 patients with bilateral and symmetrical disease who were randomized to receive laser treatment plus topical antibiotics at affected sites on one side of the body and only topical antibiotics on affected sites on the contralateral side.

The patients had a mean age of 41 years, and 15 of them had Hurley stage II hidradenitis suppurativa, which is characterized by recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. The other seven patients had stage III disease, which is exemplified by diffuse or near diffuse involvement, or multiple interconnected tracts and abscesses across the entire area.

Half of the 22 patients had Fitzpatrick skin type III, followed by 4 patients with type V, 3 with type IV, 3 with type II, and 1 with type VI.

After a series of up to four laser treatment sessions conducted once per month, there was a significant improvement in clinical scoring criteria based on a modified Hidradenitis Suppurativa European Research Group (HISERG) scale at all three anatomical sites treated with the laser (groin, axilla, and inframammary sites).

Compared with control sites, laser treatment improved the modified HISERG scale by the greatest amount for inguinal lesions (68% vs. 2%). Laser treatment also significantly improved HISERG scale scores of lesions in the axilla (63% vs. −11%) and at inframammary sites (30% vs. −71%).

Dr. Tierney reported that their research was supported by a Cutting Edge Research Grant from the American Society for Dermatologic Surgery and the Shahani Fund, a private individual donor that supports research at Henry Ford Hospital. Neither Dr. Tierney nor Dr. Hamzavi had any conflicts of interest to disclose.

At 2 months after the end of treatment, the patients continued to have significantly better modified HISERG scale scores at all sites combined, compared with all control sites combined.

The differences in response to laser treatment among anatomical sites appeared to be driven by the properties and distribution of hair at the site (density, volume, thickness, and proportion of follicles in anagen phase), according to the investigators.

The inguinal lesions of a patient with a 15-year history of disease are shown.

Lesion improvement is seen 2 months after four monthly laser treatments. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

VANCOUVER, B.C. — Fractional photothermolysis is superior to pulsed dye laser treatment for improving the cosmetic appearance of Mohs surgical scars and was preferred by all patients, despite being more painful, according to the first study comparing the two modalities.

The pulsed dye laser is the standard treatment for surgical scars, but it seems to primarily improve erythema, while fractional photothermolysis seems to mainly improve scar consistency, lead author Dr. Emily P. Tierney said in an interview.

It was surprising, then, to find that fractional photothermolysis outperformed the pulsed dye laser in reducing scar erythema. "My hypothesis in doing the study was that [fractional photothermolysis] would have improvements above and beyond the pulsed dye likely in terms of scar thickness and scar texture, but that the pulsed dye would have greater improvements in terms of the red component of scars," explained Dr. Tierney, a dermatologic surgeon with the Henry Ford Health System, Detroit.

The randomized, double-blind study, presented as a poster at the annual meeting of the American College of Mohs Surgery, involved 12 patients who had undergone Mohs surgery. All 12 scars were located on the face, neck, or chest, and 8 of them were hypopigmented.

In each patient, after application of lidocaine gel, half of each scar was treated with fractional photothermolysis (Fraxel SR, Reliant Technologies Inc.) and half treated with a pulsed dye laser (V-Beam, Candela Corp.). The patients received four treatments at 2-week intervals.

Dr. Tierney reported that she had no conflicts of interest in association with the research.

The same blinded physicians assessed the scars at each treatment and 1 month after the last treatment. All assessments were done in person, which permitted better evaluation of the scars' 3-D features. The physicians rated cosmetic outcomes using a quartile scale, so a one-quartile increase corresponded to a 25% improvement.

Compared with pulsed dye laser, fractional photothermolysis resulted in significantly greater improvements in scar thickness (mean improvement, 50%-75% vs. 0–25%), scar dyspigmentation (75% vs. 25%), color and texture of the subset of hypopigmented scars (50% vs. 0), and overall cosmetic outcome (75% vs. 50%). The two treatments both yielded a 50% improvement in scar texture.

Patients experienced significantly greater pain with the fractional photothermolysis than with the pulsed dye laser, according to Dr. Tierney, but neither treatment produced any other adverse effects.

At the end of the study, patients were offered additional treatment for the half of the scar with lesser improvement, and "uniformly, all of my 12 patients wanted the entire scar treated with Fraxel, so patients could see the significant difference between the two sides as well," she said, concluding that fractional photothermolysis appears to be the superior treatment and may expand the options available to patients.

All of the study patients started treatment 2–3 months after their surgery, but the best timing is unknown.

"That is something that we are going to have to look at in future studies—just where that optimal window is for scar remodeling," she commented. "Perhaps 2 months is too late or it may even be a little bit on the early side." To better define that optimal window, she and her colleagues are planning studies in which patients will be treated at varying times after surgery.

"The frequency of treatment is also an incredibly important variable in the success of both devices," she asserted, noting that treating patients every 2 weeks is very aggressive.

"I think the results that we got in terms of the before and after photos are greater than anything I have seen where people have treated with monthly or every-other-month types of intervals," Dr. Tierney concluded.

A scar is shown before being treated with pulsed dye (1) and Fraxel (2).

The same scar is shown after treatment using the two lasers as noted above. Photos courtesy Dr. Emily P. Tierney

KISSIMMEE, FLA. — Dark-skinned patients who undergo hair removal with a 1,064-nm Nd:YAG laser while taking isotretinoin do not appear to experience any long-term complications, according to a retrospective study of 11 patients.

The near-infrared wavelength of the Nd:YAG laser is absorbed less efficiently by epidermal melanin than with some other lasers, Dr. Khalil A. Khatri said in a poster presented at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients in the study underwent Nd:YAG laser (Cutera CoolGlide) treatments with a pulse duration of 10–30 milliseconds, a spot size of 10 mm, and a repetition rate of 2 Hz. Laser fluence ranged from 30 to 55 J/cm

The patients stopped taking isotretinoin for 3 days before and after each laser hair removal treatment to reduce the severity of retinoid dermatitis. After 131 laser hair removal treatments, the patients—all of whom were taking isotretinoin for severe acne—had moderate erythema and perifollicular edema. No patients experienced vesiculation, scarring, or permanent pigmentary changes during follow-up visits, which occurred at intervals of 4, 10, or 12 weeks, he reported.

Only one patient with Fitzpatrick type V skin developed discrete crusting, which resulted in a slight hyperpigmentation that spontaneously resolved in 3 months, after the last and most intense treatment with the highest fluence used, noted Dr. Khatri, who has no financial interest in the products used in the study.

KISSIMMEE, FLA. — Dark-skinned patients who undergo hair removal with a 1,064-nm Nd:YAG laser while taking isotretinoin do not appear to experience any long-term complications, according to a retrospective study of 11 patients.

The near-infrared wavelength of the Nd:YAG laser is absorbed less efficiently by epidermal melanin than with some other lasers, Dr. Khalil A. Khatri said in a poster presented at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients in the study underwent Nd:YAG laser (Cutera CoolGlide) treatments with a pulse duration of 10–30 milliseconds, a spot size of 10 mm, and a repetition rate of 2 Hz. Laser fluence ranged from 30 to 55 J/cm

The patients stopped taking isotretinoin for 3 days before and after each laser hair removal treatment to reduce the severity of retinoid dermatitis. After 131 laser hair removal treatments, the patients—all of whom were taking isotretinoin for severe acne—had moderate erythema and perifollicular edema. No patients experienced vesiculation, scarring, or permanent pigmentary changes during follow-up visits, which occurred at intervals of 4, 10, or 12 weeks, he reported.

Only one patient with Fitzpatrick type V skin developed discrete crusting, which resulted in a slight hyperpigmentation that spontaneously resolved in 3 months, after the last and most intense treatment with the highest fluence used, noted Dr. Khatri, who has no financial interest in the products used in the study.

KISSIMMEE, FLA. — Dark-skinned patients who undergo hair removal with a 1,064-nm Nd:YAG laser while taking isotretinoin do not appear to experience any long-term complications, according to a retrospective study of 11 patients.

The near-infrared wavelength of the Nd:YAG laser is absorbed less efficiently by epidermal melanin than with some other lasers, Dr. Khalil A. Khatri said in a poster presented at the annual meeting of the American Society for Laser Medicine and Surgery.

The patients in the study underwent Nd:YAG laser (Cutera CoolGlide) treatments with a pulse duration of 10–30 milliseconds, a spot size of 10 mm, and a repetition rate of 2 Hz. Laser fluence ranged from 30 to 55 J/cm

The patients stopped taking isotretinoin for 3 days before and after each laser hair removal treatment to reduce the severity of retinoid dermatitis. After 131 laser hair removal treatments, the patients—all of whom were taking isotretinoin for severe acne—had moderate erythema and perifollicular edema. No patients experienced vesiculation, scarring, or permanent pigmentary changes during follow-up visits, which occurred at intervals of 4, 10, or 12 weeks, he reported.

Only one patient with Fitzpatrick type V skin developed discrete crusting, which resulted in a slight hyperpigmentation that spontaneously resolved in 3 months, after the last and most intense treatment with the highest fluence used, noted Dr. Khatri, who has no financial interest in the products used in the study.

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

Triterpenoids, to which squalene is the immediate biologic precursor, include steroids and, thus, sterols, and represent the largest group of terpenoids, the most abundant group of botanical constituents and the most common ingredient class found in volatile oils. Consequently, triterpenoids appear in numerous botanical products with traditional and modern applications to dermatology, such as Centella asiatica (gotu kola) and propolis.

Indeed, the naturally occurring triterpenoids, oleanolic acid and ursolic acid, are known to confer anticarcinogenic and anti-inflammatory effects in certain cells (Exp. Dermatol. 2006;15:66–73). Ursolic acid and the natural triterpenoid erythrodiol have also been found to be effective in a multiple-dose 12-O-tetradecanoylphorbol-13-acetate (TPA) model of chronic dermal inflammation (Eur. J. Pharmacol. 1997;334:103–5).

Although triterpenoids are not as prevalent in as many of the highly touted herbal sources as polyphenols, this group of compounds is gaining increased attention for its anti-inflammatory and anti-tumor-promoting activity. In one trial, investigators studying the triterpenoids oleanolic acid and ursolic acid found that the former induced the differentiation of keratinocytes through peroxisome proliferator-activated receptor (PPAR)-α activation. In addition, topical application of oleanolic acid improved the recovery of epidermal permeability barrier function and increased ceramides in epidermis (Exp. Dermatol. 2006;15:66–73).

The preponderance of data on triterpenoids, though, points to the anti-tumor-promoting capacity of this copious botanical class of compounds.

 Anti-Tumor-Promoting Actions

In a study designed to identify potential anti-tumor promoters, investigators screened 21 cucurbitane triterpenoids using an in vitro assay system, and found that several of the compounds significantly inhibited Epstein-Barr virus (EBV) activation induced by the tumor promoter TPA.

These compounds were scandenoside R6, 23,24-dihydrocucurbitacin F, 25-acetyl-23,24-dihydrocucurbitacin F, 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, and cucurbitacin F. Two triterpenoids, 23,24-dihydrocucurbitacin F and 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, also displayed significant activity against skin tumor promotion in an in vivo two-stage murine carcinogenesis model (Biol. Pharm. Bull. 1994;17:668–71).

A later in vitro study conducted by the same lab to identify anti-tumor promoters considered 23 triterpenoid hydrocarbons isolated from ferns. Significant inhibitory activity against EBV induced by TPA was exhibited by hop-17(21)-ene, neohop-13(18)-ene, neohop-12-ene, taraxerane, multiflor-9(11)-ene, multiflor-8-ene, glutin-5(10)-ene, and taraxastane. In a two-stage in vivo murine carcinogenesis model using 7,12-dimethylbenz[a]anthracene (DMBA) for initiation and TPA for promotion, hop-17(21)-ene and neohop-13(18)-ene displayed significant anti-tumor promoting effects on mouse skin (Biol. Pharm. Bull. 1996;19:962–5).

Three years later, some of the same investigators, studying triterpenoids derived from Taraxacum japonicum (Compositae) roots, found that taraxasterol and taraxerol significantly inhibited the effects of TPA-induced Epstein-Barr virus early antigen (EBV-EA) induction, which is a preliminary in vitro screening approach to identifying anti-tumor-promoting agents. These compounds also exhibited potent anti-tumor-promoting activity in the two-stage murine skin carcinogenesis model initiated by DMBA and promoted by TPA (Biol. Pharm. Bull. 1999;22:606–10).

In a study from Osaka (Japan) University of Pharmaceutical Sciences, seven serratane-type triterpenoids isolated from different Picea species all exhibited potent inhibitory effects on EBV-EA activation induced by TPA, and did so more strongly than oleanolic acid. In addition, 13alpha,14alpha-epoxy-3beta-methoxyserratan-21beta-ol displayed significant anti-tumor-promoting activity in the in vivo two-stage murine carcinogenesis model (Cancer Lett. 2001;172:119–26).

The same lab subsequently studied 11 serratane-type triterpenoids isolated from various Picea species and three synthetic analogues for their potential inhibitory effects on EBV-EA activation induced by TPA. That study yielded more corroborative findings, as several of the compounds showed potent inhibitory activity, again more strongly than the oleanolic control, including 21-episerratenediol, serratenediol, diepiserratenediol, 3-beta-hydroxyserrat-14-en-21-one, and 3-alpha-methoxy-21-beta-hydroxyserrat-14-en-16-one. Furthermore, no cytotoxicity was associated with these compounds.

Of these triterpenoids, 21-episerratenediol was found to demonstrate significant inhibitory effects on skin tumor promotion in the in vivo two-stage mouse skin carcinogenesis model using DMBA for initiation and TPA for promotion. The investigators suggested that the triterpenoid 21-episerratenediol has potential as an effective cancer chemopreventive agent (Cancer Lett. 2003;196:121–6).

In a separate experiment conducted by this lab, two new serratane-type triterpenoids, 3beta-methoxyserrat-13-en-21-beta-ol and 13-beta,14beta-epoxy-3beta-methoxyserratan-21beta-ol, also isolated from Picea plants, exhibited strong anti-tumor-promoting effects on mouse skin carcinogenesis (Planta Med. 2003;69:1041–7).

This lab also showed that, in a test of the lupane-type triterpenoids isolated from the stem bark of Glochidion zeylanicum as well as synthetic analogues, glochidiol and lup-20(29)-ene-1beta,3beta-diol were the strongest inhibitors of EBV-EA activation induced by TPA. Glochidiol also exhibited the greatest inhibitory effect on skin tumor promotion (Planta Med. 2004;70:1234–6).

Other Anticarcinogenic Actions

In 2005, investigators at the University of North Carolina, Chapel Hill, published a report on cimigenol, an acid- and base-stable triterpenoid found in species such as Cimicifuga racemosa, C. dahurica, and C. japonica. These researchers had previously shown that cimigenol and some of its derivatives had strong inhibitory effects on mouse skin tumor promotion induced by TPA in a two-stage carcinogenesis test. Continuing that previous work, the investigators repeated screens of cimigenol and also tested 15 related compounds as potential anti-tumor promoters by using the in vitro, short-term TPA-induced EBV-EA activation assay (Bioorg. Med. Chem. 2005;13:1403–8).

Of these compounds, the researchers found that cimigenol-3,15-dione showed the greatest potency and, in a subsequent two-stage DMBA/TPA carcinogenesis assay, reduced, at 20 weeks, the number of papillomas per mouse to 48% of controls. Both cimigenol and cimigenol-3,15-dione were also nearly as potent as epigallocatechin gallate, a primary constituent of green tea, in terms of anti-tumor initiation activity, as demonstrated in a two-stage carcinogenesis assay of mouse skin tumors induced by peroxynitrite (initiator) and TPA (promoter).

The investigators concluded that these two triterpenoids amply demonstrate anti-tumor promotion as well as anti-tumor initiation and warrant consideration as significant cancer chemopreventive agents (Bioorg. Med. Chem. 2005;13:1403–8).

Protection Against UV

Four triterpenoids isolated from the stems of Styrax japonica were recently found to significantly inhibit matrix metalloproteinase-1 (MMP-1) in primary human skin fibroblasts induced by UV radiation. This finding is significant given the association between the upregulation of MMPs and chronic skin damage (Biol. Pharm. Bull. 2005;28:2003–6).

Previously, some of the same investigators studied the effects of 3,23-dihydroxy-20(29)-lupen-27-oic acid, a triterpenoid derived from Tiarella polyphylla, on the regulation of MMP-1 and type 1 procollagen in UV irradiation of cultured old-age human dermal fibroblasts. The triterpenoid dose-dependently induced regulation of type 1 procollagen and diminished regulation of MMP-1 at the protein level (Arch. Pharm. Res. 2004;27:1060–4).

Other Pharmacologic Actions

Triterpenoids also have been found in Boswellia serrata, an herb used in traditional medicine to treat inflammatory and arthritic conditions (and discussed in this column in November 2006, p. 17).

In a study published in 2000, the primary components and derivatives of Boswellia markedly inhibited TPA-induced increases in skin inflammation, epidermal proliferation, the number of epidermal cell layers, and tumor promotion in DMBA-initiated mice. DNA synthesis in human leukemia HL-60 cells was also shown to be inhibited by the addition of various forms of boswellic acid. The investigators suggest that such findings demonstrate the anticarcinogenic and antitumor properties of the major constituents, including triterpenoids, of this herb (Biofactors 2000;13:225–30).

The anti-inflammatory activity of several triterpenoids suggests the potential for numerous additional medical applications. A study evaluating the mechanism of anti-inflammatory activity displayed by triterpenoids on edema induced in mouse ears and paws, as well as rat skin, revealed that the inhibition of protein kinase C may play a crucial role in facilitating the anti-inflammatory activity of this class of compounds (Eur. J. Pharmacol. 2000;410:69–81).

In another study, several triterpene constituents of Vochysia pacifica Cuatrec, a South American tree used by traditional communities to treat inflammation, skin sores, asthma, and pulmonary congestion, were found to exert mild inhibitory activity on the intracellular target for new anti-inflammatory medications, namely the cAMP phosphodiesterase 4 isozyme (PDE4) (Phytother. Res. 2005;19:75–7).

Some triterpenoids have been documented as irritating (J. Asian Nat. Prod. Res. 2003;5:35–41) and others as toxic, which is not unexpected as these compounds comprise the primary constituent class in the volatile oils of plants. Given the breadth of this biochemical class, it is expected that some members would be toxic and others safe and beneficial to human health, such as the triterpenoid saponin glycyrrhizin, derived from licorice root (and featured in this column in March 2007, p. 24, and April 2007, p. 30). Triterpenoid saponins, or sapogenins, are used in some emulsifiers, including some Estée Lauder products, for their capacity to confer antifungal, anti-inflammatory, antimicrobial, and adaptogenic activity.

Conclusion

As we continue to explore botanical sources for medical and cosmetic purposes, we will learn more about the numerous triterpenoids found in plants. This class of biochemical compounds typically receives less attention than polyphenols in discussions of the most potent herbal ingredients used in dermatology, but the considerable potential of triterpenoids to be used in a broad range of cutaneous applications is gradually becoming appreciated.

Triterpenoids, to which squalene is the immediate biologic precursor, include steroids and, thus, sterols, and represent the largest group of terpenoids, the most abundant group of botanical constituents and the most common ingredient class found in volatile oils. Consequently, triterpenoids appear in numerous botanical products with traditional and modern applications to dermatology, such as Centella asiatica (gotu kola) and propolis.

Indeed, the naturally occurring triterpenoids, oleanolic acid and ursolic acid, are known to confer anticarcinogenic and anti-inflammatory effects in certain cells (Exp. Dermatol. 2006;15:66–73). Ursolic acid and the natural triterpenoid erythrodiol have also been found to be effective in a multiple-dose 12-O-tetradecanoylphorbol-13-acetate (TPA) model of chronic dermal inflammation (Eur. J. Pharmacol. 1997;334:103–5).

Although triterpenoids are not as prevalent in as many of the highly touted herbal sources as polyphenols, this group of compounds is gaining increased attention for its anti-inflammatory and anti-tumor-promoting activity. In one trial, investigators studying the triterpenoids oleanolic acid and ursolic acid found that the former induced the differentiation of keratinocytes through peroxisome proliferator-activated receptor (PPAR)-α activation. In addition, topical application of oleanolic acid improved the recovery of epidermal permeability barrier function and increased ceramides in epidermis (Exp. Dermatol. 2006;15:66–73).

The preponderance of data on triterpenoids, though, points to the anti-tumor-promoting capacity of this copious botanical class of compounds.

 Anti-Tumor-Promoting Actions

In a study designed to identify potential anti-tumor promoters, investigators screened 21 cucurbitane triterpenoids using an in vitro assay system, and found that several of the compounds significantly inhibited Epstein-Barr virus (EBV) activation induced by the tumor promoter TPA.

These compounds were scandenoside R6, 23,24-dihydrocucurbitacin F, 25-acetyl-23,24-dihydrocucurbitacin F, 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, and cucurbitacin F. Two triterpenoids, 23,24-dihydrocucurbitacin F and 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, also displayed significant activity against skin tumor promotion in an in vivo two-stage murine carcinogenesis model (Biol. Pharm. Bull. 1994;17:668–71).

A later in vitro study conducted by the same lab to identify anti-tumor promoters considered 23 triterpenoid hydrocarbons isolated from ferns. Significant inhibitory activity against EBV induced by TPA was exhibited by hop-17(21)-ene, neohop-13(18)-ene, neohop-12-ene, taraxerane, multiflor-9(11)-ene, multiflor-8-ene, glutin-5(10)-ene, and taraxastane. In a two-stage in vivo murine carcinogenesis model using 7,12-dimethylbenz[a]anthracene (DMBA) for initiation and TPA for promotion, hop-17(21)-ene and neohop-13(18)-ene displayed significant anti-tumor promoting effects on mouse skin (Biol. Pharm. Bull. 1996;19:962–5).

Three years later, some of the same investigators, studying triterpenoids derived from Taraxacum japonicum (Compositae) roots, found that taraxasterol and taraxerol significantly inhibited the effects of TPA-induced Epstein-Barr virus early antigen (EBV-EA) induction, which is a preliminary in vitro screening approach to identifying anti-tumor-promoting agents. These compounds also exhibited potent anti-tumor-promoting activity in the two-stage murine skin carcinogenesis model initiated by DMBA and promoted by TPA (Biol. Pharm. Bull. 1999;22:606–10).

In a study from Osaka (Japan) University of Pharmaceutical Sciences, seven serratane-type triterpenoids isolated from different Picea species all exhibited potent inhibitory effects on EBV-EA activation induced by TPA, and did so more strongly than oleanolic acid. In addition, 13alpha,14alpha-epoxy-3beta-methoxyserratan-21beta-ol displayed significant anti-tumor-promoting activity in the in vivo two-stage murine carcinogenesis model (Cancer Lett. 2001;172:119–26).

The same lab subsequently studied 11 serratane-type triterpenoids isolated from various Picea species and three synthetic analogues for their potential inhibitory effects on EBV-EA activation induced by TPA. That study yielded more corroborative findings, as several of the compounds showed potent inhibitory activity, again more strongly than the oleanolic control, including 21-episerratenediol, serratenediol, diepiserratenediol, 3-beta-hydroxyserrat-14-en-21-one, and 3-alpha-methoxy-21-beta-hydroxyserrat-14-en-16-one. Furthermore, no cytotoxicity was associated with these compounds.

Of these triterpenoids, 21-episerratenediol was found to demonstrate significant inhibitory effects on skin tumor promotion in the in vivo two-stage mouse skin carcinogenesis model using DMBA for initiation and TPA for promotion. The investigators suggested that the triterpenoid 21-episerratenediol has potential as an effective cancer chemopreventive agent (Cancer Lett. 2003;196:121–6).

In a separate experiment conducted by this lab, two new serratane-type triterpenoids, 3beta-methoxyserrat-13-en-21-beta-ol and 13-beta,14beta-epoxy-3beta-methoxyserratan-21beta-ol, also isolated from Picea plants, exhibited strong anti-tumor-promoting effects on mouse skin carcinogenesis (Planta Med. 2003;69:1041–7).

This lab also showed that, in a test of the lupane-type triterpenoids isolated from the stem bark of Glochidion zeylanicum as well as synthetic analogues, glochidiol and lup-20(29)-ene-1beta,3beta-diol were the strongest inhibitors of EBV-EA activation induced by TPA. Glochidiol also exhibited the greatest inhibitory effect on skin tumor promotion (Planta Med. 2004;70:1234–6).

Other Anticarcinogenic Actions

In 2005, investigators at the University of North Carolina, Chapel Hill, published a report on cimigenol, an acid- and base-stable triterpenoid found in species such as Cimicifuga racemosa, C. dahurica, and C. japonica. These researchers had previously shown that cimigenol and some of its derivatives had strong inhibitory effects on mouse skin tumor promotion induced by TPA in a two-stage carcinogenesis test. Continuing that previous work, the investigators repeated screens of cimigenol and also tested 15 related compounds as potential anti-tumor promoters by using the in vitro, short-term TPA-induced EBV-EA activation assay (Bioorg. Med. Chem. 2005;13:1403–8).

Of these compounds, the researchers found that cimigenol-3,15-dione showed the greatest potency and, in a subsequent two-stage DMBA/TPA carcinogenesis assay, reduced, at 20 weeks, the number of papillomas per mouse to 48% of controls. Both cimigenol and cimigenol-3,15-dione were also nearly as potent as epigallocatechin gallate, a primary constituent of green tea, in terms of anti-tumor initiation activity, as demonstrated in a two-stage carcinogenesis assay of mouse skin tumors induced by peroxynitrite (initiator) and TPA (promoter).

The investigators concluded that these two triterpenoids amply demonstrate anti-tumor promotion as well as anti-tumor initiation and warrant consideration as significant cancer chemopreventive agents (Bioorg. Med. Chem. 2005;13:1403–8).

Protection Against UV

Four triterpenoids isolated from the stems of Styrax japonica were recently found to significantly inhibit matrix metalloproteinase-1 (MMP-1) in primary human skin fibroblasts induced by UV radiation. This finding is significant given the association between the upregulation of MMPs and chronic skin damage (Biol. Pharm. Bull. 2005;28:2003–6).

Previously, some of the same investigators studied the effects of 3,23-dihydroxy-20(29)-lupen-27-oic acid, a triterpenoid derived from Tiarella polyphylla, on the regulation of MMP-1 and type 1 procollagen in UV irradiation of cultured old-age human dermal fibroblasts. The triterpenoid dose-dependently induced regulation of type 1 procollagen and diminished regulation of MMP-1 at the protein level (Arch. Pharm. Res. 2004;27:1060–4).

Other Pharmacologic Actions

Triterpenoids also have been found in Boswellia serrata, an herb used in traditional medicine to treat inflammatory and arthritic conditions (and discussed in this column in November 2006, p. 17).

In a study published in 2000, the primary components and derivatives of Boswellia markedly inhibited TPA-induced increases in skin inflammation, epidermal proliferation, the number of epidermal cell layers, and tumor promotion in DMBA-initiated mice. DNA synthesis in human leukemia HL-60 cells was also shown to be inhibited by the addition of various forms of boswellic acid. The investigators suggest that such findings demonstrate the anticarcinogenic and antitumor properties of the major constituents, including triterpenoids, of this herb (Biofactors 2000;13:225–30).

The anti-inflammatory activity of several triterpenoids suggests the potential for numerous additional medical applications. A study evaluating the mechanism of anti-inflammatory activity displayed by triterpenoids on edema induced in mouse ears and paws, as well as rat skin, revealed that the inhibition of protein kinase C may play a crucial role in facilitating the anti-inflammatory activity of this class of compounds (Eur. J. Pharmacol. 2000;410:69–81).

In another study, several triterpene constituents of Vochysia pacifica Cuatrec, a South American tree used by traditional communities to treat inflammation, skin sores, asthma, and pulmonary congestion, were found to exert mild inhibitory activity on the intracellular target for new anti-inflammatory medications, namely the cAMP phosphodiesterase 4 isozyme (PDE4) (Phytother. Res. 2005;19:75–7).

Some triterpenoids have been documented as irritating (J. Asian Nat. Prod. Res. 2003;5:35–41) and others as toxic, which is not unexpected as these compounds comprise the primary constituent class in the volatile oils of plants. Given the breadth of this biochemical class, it is expected that some members would be toxic and others safe and beneficial to human health, such as the triterpenoid saponin glycyrrhizin, derived from licorice root (and featured in this column in March 2007, p. 24, and April 2007, p. 30). Triterpenoid saponins, or sapogenins, are used in some emulsifiers, including some Estée Lauder products, for their capacity to confer antifungal, anti-inflammatory, antimicrobial, and adaptogenic activity.

Conclusion

As we continue to explore botanical sources for medical and cosmetic purposes, we will learn more about the numerous triterpenoids found in plants. This class of biochemical compounds typically receives less attention than polyphenols in discussions of the most potent herbal ingredients used in dermatology, but the considerable potential of triterpenoids to be used in a broad range of cutaneous applications is gradually becoming appreciated.

Triterpenoids, to which squalene is the immediate biologic precursor, include steroids and, thus, sterols, and represent the largest group of terpenoids, the most abundant group of botanical constituents and the most common ingredient class found in volatile oils. Consequently, triterpenoids appear in numerous botanical products with traditional and modern applications to dermatology, such as Centella asiatica (gotu kola) and propolis.

Indeed, the naturally occurring triterpenoids, oleanolic acid and ursolic acid, are known to confer anticarcinogenic and anti-inflammatory effects in certain cells (Exp. Dermatol. 2006;15:66–73). Ursolic acid and the natural triterpenoid erythrodiol have also been found to be effective in a multiple-dose 12-O-tetradecanoylphorbol-13-acetate (TPA) model of chronic dermal inflammation (Eur. J. Pharmacol. 1997;334:103–5).

Although triterpenoids are not as prevalent in as many of the highly touted herbal sources as polyphenols, this group of compounds is gaining increased attention for its anti-inflammatory and anti-tumor-promoting activity. In one trial, investigators studying the triterpenoids oleanolic acid and ursolic acid found that the former induced the differentiation of keratinocytes through peroxisome proliferator-activated receptor (PPAR)-α activation. In addition, topical application of oleanolic acid improved the recovery of epidermal permeability barrier function and increased ceramides in epidermis (Exp. Dermatol. 2006;15:66–73).

The preponderance of data on triterpenoids, though, points to the anti-tumor-promoting capacity of this copious botanical class of compounds.

 Anti-Tumor-Promoting Actions

In a study designed to identify potential anti-tumor promoters, investigators screened 21 cucurbitane triterpenoids using an in vitro assay system, and found that several of the compounds significantly inhibited Epstein-Barr virus (EBV) activation induced by the tumor promoter TPA.

These compounds were scandenoside R6, 23,24-dihydrocucurbitacin F, 25-acetyl-23,24-dihydrocucurbitacin F, 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, and cucurbitacin F. Two triterpenoids, 23,24-dihydrocucurbitacin F and 2-O-beta-D-glucopyranosyl-23,24-dihydrocucurbitacin F, also displayed significant activity against skin tumor promotion in an in vivo two-stage murine carcinogenesis model (Biol. Pharm. Bull. 1994;17:668–71).

A later in vitro study conducted by the same lab to identify anti-tumor promoters considered 23 triterpenoid hydrocarbons isolated from ferns. Significant inhibitory activity against EBV induced by TPA was exhibited by hop-17(21)-ene, neohop-13(18)-ene, neohop-12-ene, taraxerane, multiflor-9(11)-ene, multiflor-8-ene, glutin-5(10)-ene, and taraxastane. In a two-stage in vivo murine carcinogenesis model using 7,12-dimethylbenz[a]anthracene (DMBA) for initiation and TPA for promotion, hop-17(21)-ene and neohop-13(18)-ene displayed significant anti-tumor promoting effects on mouse skin (Biol. Pharm. Bull. 1996;19:962–5).

Three years later, some of the same investigators, studying triterpenoids derived from Taraxacum japonicum (Compositae) roots, found that taraxasterol and taraxerol significantly inhibited the effects of TPA-induced Epstein-Barr virus early antigen (EBV-EA) induction, which is a preliminary in vitro screening approach to identifying anti-tumor-promoting agents. These compounds also exhibited potent anti-tumor-promoting activity in the two-stage murine skin carcinogenesis model initiated by DMBA and promoted by TPA (Biol. Pharm. Bull. 1999;22:606–10).

In a study from Osaka (Japan) University of Pharmaceutical Sciences, seven serratane-type triterpenoids isolated from different Picea species all exhibited potent inhibitory effects on EBV-EA activation induced by TPA, and did so more strongly than oleanolic acid. In addition, 13alpha,14alpha-epoxy-3beta-methoxyserratan-21beta-ol displayed significant anti-tumor-promoting activity in the in vivo two-stage murine carcinogenesis model (Cancer Lett. 2001;172:119–26).

The same lab subsequently studied 11 serratane-type triterpenoids isolated from various Picea species and three synthetic analogues for their potential inhibitory effects on EBV-EA activation induced by TPA. That study yielded more corroborative findings, as several of the compounds showed potent inhibitory activity, again more strongly than the oleanolic control, including 21-episerratenediol, serratenediol, diepiserratenediol, 3-beta-hydroxyserrat-14-en-21-one, and 3-alpha-methoxy-21-beta-hydroxyserrat-14-en-16-one. Furthermore, no cytotoxicity was associated with these compounds.

Of these triterpenoids, 21-episerratenediol was found to demonstrate significant inhibitory effects on skin tumor promotion in the in vivo two-stage mouse skin carcinogenesis model using DMBA for initiation and TPA for promotion. The investigators suggested that the triterpenoid 21-episerratenediol has potential as an effective cancer chemopreventive agent (Cancer Lett. 2003;196:121–6).

In a separate experiment conducted by this lab, two new serratane-type triterpenoids, 3beta-methoxyserrat-13-en-21-beta-ol and 13-beta,14beta-epoxy-3beta-methoxyserratan-21beta-ol, also isolated from Picea plants, exhibited strong anti-tumor-promoting effects on mouse skin carcinogenesis (Planta Med. 2003;69:1041–7).

This lab also showed that, in a test of the lupane-type triterpenoids isolated from the stem bark of Glochidion zeylanicum as well as synthetic analogues, glochidiol and lup-20(29)-ene-1beta,3beta-diol were the strongest inhibitors of EBV-EA activation induced by TPA. Glochidiol also exhibited the greatest inhibitory effect on skin tumor promotion (Planta Med. 2004;70:1234–6).

Other Anticarcinogenic Actions

In 2005, investigators at the University of North Carolina, Chapel Hill, published a report on cimigenol, an acid- and base-stable triterpenoid found in species such as Cimicifuga racemosa, C. dahurica, and C. japonica. These researchers had previously shown that cimigenol and some of its derivatives had strong inhibitory effects on mouse skin tumor promotion induced by TPA in a two-stage carcinogenesis test. Continuing that previous work, the investigators repeated screens of cimigenol and also tested 15 related compounds as potential anti-tumor promoters by using the in vitro, short-term TPA-induced EBV-EA activation assay (Bioorg. Med. Chem. 2005;13:1403–8).

Of these compounds, the researchers found that cimigenol-3,15-dione showed the greatest potency and, in a subsequent two-stage DMBA/TPA carcinogenesis assay, reduced, at 20 weeks, the number of papillomas per mouse to 48% of controls. Both cimigenol and cimigenol-3,15-dione were also nearly as potent as epigallocatechin gallate, a primary constituent of green tea, in terms of anti-tumor initiation activity, as demonstrated in a two-stage carcinogenesis assay of mouse skin tumors induced by peroxynitrite (initiator) and TPA (promoter).

The investigators concluded that these two triterpenoids amply demonstrate anti-tumor promotion as well as anti-tumor initiation and warrant consideration as significant cancer chemopreventive agents (Bioorg. Med. Chem. 2005;13:1403–8).

Protection Against UV

Four triterpenoids isolated from the stems of Styrax japonica were recently found to significantly inhibit matrix metalloproteinase-1 (MMP-1) in primary human skin fibroblasts induced by UV radiation. This finding is significant given the association between the upregulation of MMPs and chronic skin damage (Biol. Pharm. Bull. 2005;28:2003–6).

Previously, some of the same investigators studied the effects of 3,23-dihydroxy-20(29)-lupen-27-oic acid, a triterpenoid derived from Tiarella polyphylla, on the regulation of MMP-1 and type 1 procollagen in UV irradiation of cultured old-age human dermal fibroblasts. The triterpenoid dose-dependently induced regulation of type 1 procollagen and diminished regulation of MMP-1 at the protein level (Arch. Pharm. Res. 2004;27:1060–4).

Other Pharmacologic Actions

Triterpenoids also have been found in Boswellia serrata, an herb used in traditional medicine to treat inflammatory and arthritic conditions (and discussed in this column in November 2006, p. 17).

In a study published in 2000, the primary components and derivatives of Boswellia markedly inhibited TPA-induced increases in skin inflammation, epidermal proliferation, the number of epidermal cell layers, and tumor promotion in DMBA-initiated mice. DNA synthesis in human leukemia HL-60 cells was also shown to be inhibited by the addition of various forms of boswellic acid. The investigators suggest that such findings demonstrate the anticarcinogenic and antitumor properties of the major constituents, including triterpenoids, of this herb (Biofactors 2000;13:225–30).

The anti-inflammatory activity of several triterpenoids suggests the potential for numerous additional medical applications. A study evaluating the mechanism of anti-inflammatory activity displayed by triterpenoids on edema induced in mouse ears and paws, as well as rat skin, revealed that the inhibition of protein kinase C may play a crucial role in facilitating the anti-inflammatory activity of this class of compounds (Eur. J. Pharmacol. 2000;410:69–81).

In another study, several triterpene constituents of Vochysia pacifica Cuatrec, a South American tree used by traditional communities to treat inflammation, skin sores, asthma, and pulmonary congestion, were found to exert mild inhibitory activity on the intracellular target for new anti-inflammatory medications, namely the cAMP phosphodiesterase 4 isozyme (PDE4) (Phytother. Res. 2005;19:75–7).

Some triterpenoids have been documented as irritating (J. Asian Nat. Prod. Res. 2003;5:35–41) and others as toxic, which is not unexpected as these compounds comprise the primary constituent class in the volatile oils of plants. Given the breadth of this biochemical class, it is expected that some members would be toxic and others safe and beneficial to human health, such as the triterpenoid saponin glycyrrhizin, derived from licorice root (and featured in this column in March 2007, p. 24, and April 2007, p. 30). Triterpenoid saponins, or sapogenins, are used in some emulsifiers, including some Estée Lauder products, for their capacity to confer antifungal, anti-inflammatory, antimicrobial, and adaptogenic activity.

Conclusion

As we continue to explore botanical sources for medical and cosmetic purposes, we will learn more about the numerous triterpenoids found in plants. This class of biochemical compounds typically receives less attention than polyphenols in discussions of the most potent herbal ingredients used in dermatology, but the considerable potential of triterpenoids to be used in a broad range of cutaneous applications is gradually becoming appreciated.