Aesthetic Dermatology

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

Kinetin (N6-furfuryladenine or 6-furfurylaminopurine) is a plant cytokinin or phytohormone that promotes cell division, delays senescence in plants, and is reputed to aid in the restoration of skin barrier function and, possibly, in reducing the signs and symptoms of rosacea (Clin. Exp. Dermatol. 2007;32:693-5; Plant Sci. 1999;148:37-45).

Kinetin is believed to develop in cellular DNA as a product of the oxidative, secondary modification of DNA (Plant Sci. 1999;148:37-45). In 1955, it became the first cytokinin isolated from DNA (from herring sperm) as an artifactual rearrangement product of the autoclaving process (J. Cosmet. Dermatol. 2007;6:243-9; Int. J. Biol. Macromol. 2007;40:182-92).

It has since been found to be present in human urine as well as DNA freshly extracted from human cells (Int. J. Biol. Macromol. 2007;40:182-92). The preponderance of amassed experimental evidence suggests that endogenous kinetin acts in vitro and in vivo as a potent antioxidant (Plant Sci. 1999;148:37-45). Currently, it is used as an anti-aging agent in various cosmetic products (J. Cosmet. Dermatol. 2007;6:243-9; J. Cosmet. Dermatol. 2010;9:218-25). Synthetic kinetin is thought to have the capacity to neutralize free radicals as well as limit the damage to DNA and fibroblasts (Photochem. Photobiol. 2012;88:748-52).

In vitro results

Olsen et al. demonstrated in vitro in 1999 that kinetin dose-dependently protected DNA against oxidative damage mediated by the Fenton reaction, and noted that kinetin had previously been linked to anti-aging activity in plants, fruit flies, and human cells in culture (Biochem. Biophys. Res. Commun. 1999;265:499-502). The following year, Verbeke et al. showed in vitro that kinetin potently inhibited damage caused by oxidation and glycoxidation (Biochem. Biophys. Res. Commun. 2000;276:1265-70).

In 2006, Vicanova et al. analyzed the effects of active ingredients from topical and systemic skin care formulations in vitro, finding that kinetin affected the upper dermis by enhancing deposits of fibrillin-1 and elastin fibers as well as their organization perpendicular to the dermal-epidermal junction. In the epidermis, kinetin stimulated keratinocyte production. Further, the investigators noted that the combination of topically applied kinetin with Imedeen Time Perfection ingredients (i.e., BioMarine Complex, grape seed extract, tomato extract, and vitamin C) supplemented systemically into culture medium yielded complementary benefits to dermal and epidermal development (Ann. N.Y. Acad. Sci. 2006;1067:337-42).

It is worth noting that in a study by Tournas et al. published the same month, investigators found that the topical application of a combination of vitamins C and E and ferulic acid yielded photoprotection to pig skin at 5 times the minimal erythema dose (MED) while individual antioxidants to which it was compared (i.e., coenzyme Q10, idebenone, and kinetin) delivered no photoprotective effects (J. Invest. Dermatol. 2006;126:1185-7). Nevertheless, Barciszewski et al. have observed that kinetin is the first stable secondary DNA damage product characterized by well defined cytokinin and anti-aging activity, with data showing that it has delayed human cellular aging in culture (Int. J. Biol. Macromol. 2007;40:182-92).

Rosacea

In 2007, Wu et al. performed a 12-week open-label study in 15 women and 3 men (aged 30-67 years) to ascertain the tolerability and efficacy of kinetin 0.1% lotion in the treatment of mild to moderate facial rosacea. Patients (17 of whom completed the study) applied the lotion twice daily, also daily applying an SPF 30 sunscreen. By week 4, significant improvements were observed in the reduction of skin roughness and mottled hyperpigmentation. Subject assessments at each 4-week interval after baseline and after 12 weeks revealed that kinetin 0.1% was well tolerated and effective for mild to moderate inflammatory rosacea (Clin. Exp. Dermatol. 2007;32:693-5).

Anti-aging

A 2002 study by J.L. McCullough and G.D. Weinstein represented the first evidence of the efficacy of topical kinetin in human beings, with twice-daily application for 24 weeks found to ameliorate skin texture, color, and blotchiness while diminishing rhytides and transepidermal water loss (J. Cosmet. Dermatol. 2002;15:29-32).

Two years later, T. Kimura and K. Doi showed that topical administration of kinetin improved the texture, wrinkling, and pigmentation of aged skin of hairless descendants of Mexican hairless dogs, resulting in notable depigmentation and rejuvenation after 100 days of treatment (Rejuvenation Res. 2004;7:32-9).In 2007, Chiu et al. conducted a randomized, double-blind, placebo-controlled, split-face comparative study in 52 Taiwanese subjects aged 30-60 years (90% of whom were female, all of whom had Fitzpatrick skin types II, III, or IV) to evaluate the clinical anti-aging effects and efficacy differences between kinetin plus niacinamide (kinetin 0.03%, niacinamide 4%) and niacinamide 4% alone versus vehicle placebo.

In the combination group, significant and sustained decreases were observed in counts of spots, pores, wrinkles, and evenness as well as persistent reductions in erythema index at weeks 8 and 12. At week 12, stratum corneum hydration status also was significantly enhanced in this group. In the niacinamide-only group, pore and evenness counts were significantly decreased at week 8, with declines in wrinkle counts emerging at week 12. The investigators concluded that kinetin and niacinamide display synergistic and dynamic anti-aging effects, showing substantial potential as topical anti-aging cosmeceutical agents (J. Cosmet. Dermatol. 2007;6:243-9).

However, Levin et al. noted in 2010 that while the effects of kinetin have been established in plants and its antioxidant properties have been displayed in vitro, the anti-aging effects and clinical efficacy ascribed to kinetin have been based on limited evidence, with no studies extant on the percutaneous absorption of kinetin. They added that research elucidating the mechanisms through which kinetin appears to improve skin barrier function, texture, and pigmentation also are lacking (J. Clin. Aesthet. Dermatol. 2010;3:22-41).

In 2012, Campos et al. assessed the effects on hydration, viscoelastic characteristics, and photoprotection of cosmetic preparations containing a dispersion of liposome with magnesium ascorbyl phosphate, alpha-lipoic acid, and kinetin. They observed that the formulation protected hairless mouse skin barrier function against UV harm. After 4 weeks of application on human skin, the combination product was found to have improved moisturization of the stratum corneum, also delivering hydration effects to deeper skin layers. The researchers concluded that the cosmetic formulation containing kinetin shows promise as a cutaneous anti-aging product (Photochem. Photobiol. 2012;88:748-52).

Conclusion

While some experimental and clinical results appear to suggest an anti-aging effect exerted by topically applied kinetin, much more research – particularly randomized controlled and comparison studies – are needed to provide a clearer picture as to the mechanisms and appropriate role of kinetin in the dermatologic armamentarium.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

Kinetin (N6-furfuryladenine or 6-furfurylaminopurine) is a plant cytokinin or phytohormone that promotes cell division, delays senescence in plants, and is reputed to aid in the restoration of skin barrier function and, possibly, in reducing the signs and symptoms of rosacea (Clin. Exp. Dermatol. 2007;32:693-5; Plant Sci. 1999;148:37-45).

Kinetin is believed to develop in cellular DNA as a product of the oxidative, secondary modification of DNA (Plant Sci. 1999;148:37-45). In 1955, it became the first cytokinin isolated from DNA (from herring sperm) as an artifactual rearrangement product of the autoclaving process (J. Cosmet. Dermatol. 2007;6:243-9; Int. J. Biol. Macromol. 2007;40:182-92).

It has since been found to be present in human urine as well as DNA freshly extracted from human cells (Int. J. Biol. Macromol. 2007;40:182-92). The preponderance of amassed experimental evidence suggests that endogenous kinetin acts in vitro and in vivo as a potent antioxidant (Plant Sci. 1999;148:37-45). Currently, it is used as an anti-aging agent in various cosmetic products (J. Cosmet. Dermatol. 2007;6:243-9; J. Cosmet. Dermatol. 2010;9:218-25). Synthetic kinetin is thought to have the capacity to neutralize free radicals as well as limit the damage to DNA and fibroblasts (Photochem. Photobiol. 2012;88:748-52).

In vitro results

Olsen et al. demonstrated in vitro in 1999 that kinetin dose-dependently protected DNA against oxidative damage mediated by the Fenton reaction, and noted that kinetin had previously been linked to anti-aging activity in plants, fruit flies, and human cells in culture (Biochem. Biophys. Res. Commun. 1999;265:499-502). The following year, Verbeke et al. showed in vitro that kinetin potently inhibited damage caused by oxidation and glycoxidation (Biochem. Biophys. Res. Commun. 2000;276:1265-70).

In 2006, Vicanova et al. analyzed the effects of active ingredients from topical and systemic skin care formulations in vitro, finding that kinetin affected the upper dermis by enhancing deposits of fibrillin-1 and elastin fibers as well as their organization perpendicular to the dermal-epidermal junction. In the epidermis, kinetin stimulated keratinocyte production. Further, the investigators noted that the combination of topically applied kinetin with Imedeen Time Perfection ingredients (i.e., BioMarine Complex, grape seed extract, tomato extract, and vitamin C) supplemented systemically into culture medium yielded complementary benefits to dermal and epidermal development (Ann. N.Y. Acad. Sci. 2006;1067:337-42).

It is worth noting that in a study by Tournas et al. published the same month, investigators found that the topical application of a combination of vitamins C and E and ferulic acid yielded photoprotection to pig skin at 5 times the minimal erythema dose (MED) while individual antioxidants to which it was compared (i.e., coenzyme Q10, idebenone, and kinetin) delivered no photoprotective effects (J. Invest. Dermatol. 2006;126:1185-7). Nevertheless, Barciszewski et al. have observed that kinetin is the first stable secondary DNA damage product characterized by well defined cytokinin and anti-aging activity, with data showing that it has delayed human cellular aging in culture (Int. J. Biol. Macromol. 2007;40:182-92).

Rosacea

In 2007, Wu et al. performed a 12-week open-label study in 15 women and 3 men (aged 30-67 years) to ascertain the tolerability and efficacy of kinetin 0.1% lotion in the treatment of mild to moderate facial rosacea. Patients (17 of whom completed the study) applied the lotion twice daily, also daily applying an SPF 30 sunscreen. By week 4, significant improvements were observed in the reduction of skin roughness and mottled hyperpigmentation. Subject assessments at each 4-week interval after baseline and after 12 weeks revealed that kinetin 0.1% was well tolerated and effective for mild to moderate inflammatory rosacea (Clin. Exp. Dermatol. 2007;32:693-5).

Anti-aging

A 2002 study by J.L. McCullough and G.D. Weinstein represented the first evidence of the efficacy of topical kinetin in human beings, with twice-daily application for 24 weeks found to ameliorate skin texture, color, and blotchiness while diminishing rhytides and transepidermal water loss (J. Cosmet. Dermatol. 2002;15:29-32).

Two years later, T. Kimura and K. Doi showed that topical administration of kinetin improved the texture, wrinkling, and pigmentation of aged skin of hairless descendants of Mexican hairless dogs, resulting in notable depigmentation and rejuvenation after 100 days of treatment (Rejuvenation Res. 2004;7:32-9).In 2007, Chiu et al. conducted a randomized, double-blind, placebo-controlled, split-face comparative study in 52 Taiwanese subjects aged 30-60 years (90% of whom were female, all of whom had Fitzpatrick skin types II, III, or IV) to evaluate the clinical anti-aging effects and efficacy differences between kinetin plus niacinamide (kinetin 0.03%, niacinamide 4%) and niacinamide 4% alone versus vehicle placebo.

In the combination group, significant and sustained decreases were observed in counts of spots, pores, wrinkles, and evenness as well as persistent reductions in erythema index at weeks 8 and 12. At week 12, stratum corneum hydration status also was significantly enhanced in this group. In the niacinamide-only group, pore and evenness counts were significantly decreased at week 8, with declines in wrinkle counts emerging at week 12. The investigators concluded that kinetin and niacinamide display synergistic and dynamic anti-aging effects, showing substantial potential as topical anti-aging cosmeceutical agents (J. Cosmet. Dermatol. 2007;6:243-9).

However, Levin et al. noted in 2010 that while the effects of kinetin have been established in plants and its antioxidant properties have been displayed in vitro, the anti-aging effects and clinical efficacy ascribed to kinetin have been based on limited evidence, with no studies extant on the percutaneous absorption of kinetin. They added that research elucidating the mechanisms through which kinetin appears to improve skin barrier function, texture, and pigmentation also are lacking (J. Clin. Aesthet. Dermatol. 2010;3:22-41).

In 2012, Campos et al. assessed the effects on hydration, viscoelastic characteristics, and photoprotection of cosmetic preparations containing a dispersion of liposome with magnesium ascorbyl phosphate, alpha-lipoic acid, and kinetin. They observed that the formulation protected hairless mouse skin barrier function against UV harm. After 4 weeks of application on human skin, the combination product was found to have improved moisturization of the stratum corneum, also delivering hydration effects to deeper skin layers. The researchers concluded that the cosmetic formulation containing kinetin shows promise as a cutaneous anti-aging product (Photochem. Photobiol. 2012;88:748-52).

Conclusion

While some experimental and clinical results appear to suggest an anti-aging effect exerted by topically applied kinetin, much more research – particularly randomized controlled and comparison studies – are needed to provide a clearer picture as to the mechanisms and appropriate role of kinetin in the dermatologic armamentarium.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

Kinetin (N6-furfuryladenine or 6-furfurylaminopurine) is a plant cytokinin or phytohormone that promotes cell division, delays senescence in plants, and is reputed to aid in the restoration of skin barrier function and, possibly, in reducing the signs and symptoms of rosacea (Clin. Exp. Dermatol. 2007;32:693-5; Plant Sci. 1999;148:37-45).

Kinetin is believed to develop in cellular DNA as a product of the oxidative, secondary modification of DNA (Plant Sci. 1999;148:37-45). In 1955, it became the first cytokinin isolated from DNA (from herring sperm) as an artifactual rearrangement product of the autoclaving process (J. Cosmet. Dermatol. 2007;6:243-9; Int. J. Biol. Macromol. 2007;40:182-92).

It has since been found to be present in human urine as well as DNA freshly extracted from human cells (Int. J. Biol. Macromol. 2007;40:182-92). The preponderance of amassed experimental evidence suggests that endogenous kinetin acts in vitro and in vivo as a potent antioxidant (Plant Sci. 1999;148:37-45). Currently, it is used as an anti-aging agent in various cosmetic products (J. Cosmet. Dermatol. 2007;6:243-9; J. Cosmet. Dermatol. 2010;9:218-25). Synthetic kinetin is thought to have the capacity to neutralize free radicals as well as limit the damage to DNA and fibroblasts (Photochem. Photobiol. 2012;88:748-52).

In vitro results

Olsen et al. demonstrated in vitro in 1999 that kinetin dose-dependently protected DNA against oxidative damage mediated by the Fenton reaction, and noted that kinetin had previously been linked to anti-aging activity in plants, fruit flies, and human cells in culture (Biochem. Biophys. Res. Commun. 1999;265:499-502). The following year, Verbeke et al. showed in vitro that kinetin potently inhibited damage caused by oxidation and glycoxidation (Biochem. Biophys. Res. Commun. 2000;276:1265-70).

In 2006, Vicanova et al. analyzed the effects of active ingredients from topical and systemic skin care formulations in vitro, finding that kinetin affected the upper dermis by enhancing deposits of fibrillin-1 and elastin fibers as well as their organization perpendicular to the dermal-epidermal junction. In the epidermis, kinetin stimulated keratinocyte production. Further, the investigators noted that the combination of topically applied kinetin with Imedeen Time Perfection ingredients (i.e., BioMarine Complex, grape seed extract, tomato extract, and vitamin C) supplemented systemically into culture medium yielded complementary benefits to dermal and epidermal development (Ann. N.Y. Acad. Sci. 2006;1067:337-42).

It is worth noting that in a study by Tournas et al. published the same month, investigators found that the topical application of a combination of vitamins C and E and ferulic acid yielded photoprotection to pig skin at 5 times the minimal erythema dose (MED) while individual antioxidants to which it was compared (i.e., coenzyme Q10, idebenone, and kinetin) delivered no photoprotective effects (J. Invest. Dermatol. 2006;126:1185-7). Nevertheless, Barciszewski et al. have observed that kinetin is the first stable secondary DNA damage product characterized by well defined cytokinin and anti-aging activity, with data showing that it has delayed human cellular aging in culture (Int. J. Biol. Macromol. 2007;40:182-92).

Rosacea

In 2007, Wu et al. performed a 12-week open-label study in 15 women and 3 men (aged 30-67 years) to ascertain the tolerability and efficacy of kinetin 0.1% lotion in the treatment of mild to moderate facial rosacea. Patients (17 of whom completed the study) applied the lotion twice daily, also daily applying an SPF 30 sunscreen. By week 4, significant improvements were observed in the reduction of skin roughness and mottled hyperpigmentation. Subject assessments at each 4-week interval after baseline and after 12 weeks revealed that kinetin 0.1% was well tolerated and effective for mild to moderate inflammatory rosacea (Clin. Exp. Dermatol. 2007;32:693-5).

Anti-aging

A 2002 study by J.L. McCullough and G.D. Weinstein represented the first evidence of the efficacy of topical kinetin in human beings, with twice-daily application for 24 weeks found to ameliorate skin texture, color, and blotchiness while diminishing rhytides and transepidermal water loss (J. Cosmet. Dermatol. 2002;15:29-32).

Two years later, T. Kimura and K. Doi showed that topical administration of kinetin improved the texture, wrinkling, and pigmentation of aged skin of hairless descendants of Mexican hairless dogs, resulting in notable depigmentation and rejuvenation after 100 days of treatment (Rejuvenation Res. 2004;7:32-9).In 2007, Chiu et al. conducted a randomized, double-blind, placebo-controlled, split-face comparative study in 52 Taiwanese subjects aged 30-60 years (90% of whom were female, all of whom had Fitzpatrick skin types II, III, or IV) to evaluate the clinical anti-aging effects and efficacy differences between kinetin plus niacinamide (kinetin 0.03%, niacinamide 4%) and niacinamide 4% alone versus vehicle placebo.

In the combination group, significant and sustained decreases were observed in counts of spots, pores, wrinkles, and evenness as well as persistent reductions in erythema index at weeks 8 and 12. At week 12, stratum corneum hydration status also was significantly enhanced in this group. In the niacinamide-only group, pore and evenness counts were significantly decreased at week 8, with declines in wrinkle counts emerging at week 12. The investigators concluded that kinetin and niacinamide display synergistic and dynamic anti-aging effects, showing substantial potential as topical anti-aging cosmeceutical agents (J. Cosmet. Dermatol. 2007;6:243-9).

However, Levin et al. noted in 2010 that while the effects of kinetin have been established in plants and its antioxidant properties have been displayed in vitro, the anti-aging effects and clinical efficacy ascribed to kinetin have been based on limited evidence, with no studies extant on the percutaneous absorption of kinetin. They added that research elucidating the mechanisms through which kinetin appears to improve skin barrier function, texture, and pigmentation also are lacking (J. Clin. Aesthet. Dermatol. 2010;3:22-41).

In 2012, Campos et al. assessed the effects on hydration, viscoelastic characteristics, and photoprotection of cosmetic preparations containing a dispersion of liposome with magnesium ascorbyl phosphate, alpha-lipoic acid, and kinetin. They observed that the formulation protected hairless mouse skin barrier function against UV harm. After 4 weeks of application on human skin, the combination product was found to have improved moisturization of the stratum corneum, also delivering hydration effects to deeper skin layers. The researchers concluded that the cosmetic formulation containing kinetin shows promise as a cutaneous anti-aging product (Photochem. Photobiol. 2012;88:748-52).

Conclusion

While some experimental and clinical results appear to suggest an anti-aging effect exerted by topically applied kinetin, much more research – particularly randomized controlled and comparison studies – are needed to provide a clearer picture as to the mechanisms and appropriate role of kinetin in the dermatologic armamentarium.

Dr. Baumann is chief executive officer of the Baumann Cosmetic & Research Institute in the Design District in Miami. She founded the Cosmetic Dermatology Center at the University of Miami in 1997. Dr. Baumann wrote the textbook “Cosmetic Dermatology: Principles and Practice” (New York: McGraw-Hill, 2002), and a book for consumers, “The Skin Type Solution” (New York: Bantam Dell, 2006). She has contributed to the Cosmeceutical Critique column in Dermatology News since January 2001. Her latest book, “Cosmeceuticals and Cosmetic Ingredients,” was published in November 2014. Dr. Baumann has received funding for clinical grants from Allergan, Aveeno, Avon Products, Evolus, Galderma, GlaxoSmithKline, Kythera Biopharmaceuticals, Mary Kay, Medicis Pharmaceuticals, Neutrogena, Philosophy,Topix Pharmaceuticals, and Unilever.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.