Xeomin Approved for Medical & Cosmetic Use

Like other botulinum products, this one was developed for medically necessary purposes such as treating eyelid spasm or chronic neck pain. However, it has also been used in 2 clinical trials for cosmetic improvement of glabellar lines (wrinkles between the eyebrows). The product offered a noticeable minimization of frown lines compared to placebo at the 30 day mark after treatment. Since this product has basically the same active ingredient as Botox and Dysport and works in the same way by blocking nerve signals to the muscles, Xeomin moved fairly quickly through the FDA approval process.

Product Safety Profile

The company will be required to continue testing for some time to further evaluate safety in various patient groups, but the results and the overall risk profile are expected to be similar to other botulinum toxins. The protein solution which carries the toxin molecule is different in Xeomin than in Botox and is hoped to cause fewer side effects in the larger doses used to treat medical conditions. However, many dermatologists feel this change won’t have any impact when it comes to the small doses used for cosmetic treatment. The most commonly mentioned side effect among patients receiving wrinkle treatment with Xeomin was headache.

No Comparison Trials Yet Done

So far, no split face studies have been conducted in the U.S. comparing Xeomin to Botox or Dysport to determine which one is the most effective for wrinkle reduction. It’s not likely that Xeomin will provide significantly longer lasting effects than other botulinum injectables. Brow wrinkles become noticeable again as the nerves in the face repair themselves, causing the muscles to begin contracting normally and reinforcing frown lines. It’s not so much the drug “wearing off” as the body healing itself. This tends to occur at a similar rate in most people after exposure to botulinum toxin. Some patients can go longer between Botox treatments over time, but this effect varies from one individual to another. In the final analysis, the main advantage of having similar products competing is likely to be greater affordability for consumers.

Prevention

Since the development of acne has both genetic and hormonal components, there is no sure-fire way to prevent it. However, there are steps preteens can take to limit outbreaks. This includes washing their face regularly with a gentle cleanser and lukewarm water. Washing twice a day when they brush their teeth is a reasonable schedule. A dermatologist can recommend face and body soaps for sensitive skin that will decrease the chances of irritation or over-drying. Rinsing off immediately after exercise or sports activities is also important for removing sweat and oils that can provide a breeding ground for bacteria.

With younger and younger children becoming fashion conscious, the use of personal care products such as hair gel and cosmetics can be a contributing factor in acne. Even some lotions can clog pores. Minimizing the number of products used and choosing those that are labeled as “noncomedogenic” may help.

Medications

Currently, no medications are approved by the FDA for the treatment of acne in children 12 years old and younger. However, this does not mean a dermatologist cannot prescribe one if he or she feels it would be safe and provide some benefit. Over the counter products such as benzoyl peroxide or salicylic acid creams may be appropriate for preteens who are mature enough to follow the instructions safely and consistently.

Recently, pediatric dermatologists have also begun testing topical retinoids for acne treatment in children. For mild to moderate acne, .04% tretinoin has shown good results with only mild, temporary side effects such as skin irritation. In a study of 40 children from 8-12 years old, 75% showed noticeable clearing of their symptoms after 12 weeks of treatment with this microsphere gel. Three months may seem like a long time to a child, but unfortunately there are no quick fixes for acne at any age.

Topical Treatments Have Limited Usefulness

Adult female patients often develop acne along the jaw line and on the neck. The skin in these areas is quite delicate. Most topical products are mildly irritating in the best of circumstances. They may hurt more than they help when applied to sensitive skin. Over the counter and prescription medications for topical acne remedies don’t vary much in their ingredients or in the way they affect the skin. Benzoyl peroxide kills the bacteria that contribute to acne symptoms. Salicylic acid helps slough off dead skin and clear pores. Irritation, redness, burning, and dryness are all common side effects of these ingredients.

Oral Medications Commonly Prescribed

Low doses of antibiotics are sometimes prescribed for adult patients who do not respond to topical acne remedies. Doxycycline and minocycline are two examples of drugs that are frequently used for this purpose. The treatment may last for an extended period of time. Unfortunately, some women experience chronic yeast infections when they take antibiotics for acne. This may require repeated treatment with an oral medication such as Diflucan or an over the counter remedy such as Monistat. Antibiotics may also interfere with the effectiveness of hormonal birth control medications.

Hormonal birth control itself is another potential acne treatment for women who also do not wish to become pregnant. It usually takes several months for the hormone levels in the body to create an improvement in the skin. In addition, this remedy does not work for all women (which can be a disappointing discovery after a patient has waited 6 months or more to see results). It also carries a risk of serious side effects – especially for women who smoke.

Isotretinoin (an oral vitamin A medication that was originally sold under the brand name Accutane) may be suggested in extreme cases. Adult female patients with acne should consult with a dermatologist, their regular family physician, and their OBGYN to select the best treatment option.

Why Is The USPSTF Limiting The Scope Of Its Recommendation?

It may seem counter-intuitive since the evidence linking excessive sun exposure with skin cancer is well established for all age groups and skin types. Common sense would indicate that everyone could benefit from understanding how to practice better sun safety. That’s the stance the American Academy of Dermatology Association (AADA) is taking in its response. The Association has long been a strong proponent of education for everyone, so it’s not surprising that they feel the USPSTF didn’t go far enough in this update.

Lack of Data Is Holding the USPSTF Back

The organization is not saying that sun protection is unimportant for older adults or those with darker skin. They have simply concluded that they don’t have enough evidence to weigh the benefits vs. the risks of counseling for people outside the current target group. Here’s the reasoning behind the decision:

1. The risk of developing skin cancer later in life is increased most by sunburn during childhood, adolescence, and early adulthood. The risk of skin cancer does increase somewhat over time with repeated sun exposure in later adulthood. It’s just not as dramatic as the heightened risk from early exposure. This makes it easier to justify intervention in sun exposure practices for kids and young adults because it may be possible to achieve maximum risk reduction at that time.
2. The individuals enrolled in most studies regarding the effectiveness of skin cancer counseling were overwhelmingly fair skinned because this group is at higher risk of skin cancer. There is little similar data collected for people with darker skin (even though people of all skin types can and do develop skin cancer). Such trials need to be carried out rather than just assuming that other demographics can’t benefit from sun-protection counseling.

Facial Cleansers

Keeping the skin’s lipid barrier as intact as possible during washing is critical for reducing dryness and irritation. Gentle, pH balanced cleansers work best. Adult skin is slightly acidic – somewhere in the 5.5 range. So, products that have a pH between 5.5 and neutral (a pH of 7) are usually the closest match for the skin’s natural balance. Here’s a list of common facial cleansers with their pH rating.

A product that is more alkaline tends to be harsh and strips too much oil from the skin. Alcohol is an example of a cleanser ingredient that is alkaline and should be avoided by individuals with sensitive skin. Many bar soaps contain lye which makes them highly alkaline as well. In contrast, ingredients such as salicylic acid are significantly more acidic than normal skin. Mild acids are sometimes recommended for conditions like acne. But using multiple skin care products that are acidic can cause irritation. So, patients should use these only as directed by their dermatologist.

Moisturizers & Sunscreen

Facial cleansers that contain moisturizers can be helpful for keeping skin hydrated. Moisturizing creams and lotions can also be used after washing to keep skin from drying. This is especially beneficial for acne and rosacea patients who are using topical medications that cause dryness as a side effect. Ceramide, HA, and glycerin are other ingredients to look for in a moisturizer. Silicone additives such as Dimethicone that help keep moisture in the skin can be helpful for some patients.

The AAD recommends non-comedogenic, oil-free products for patients with acne. This applies to everything from makeup and moisturizers to sunscreen. Non-greasy spray or gel based sunscreens can also be a good choice for acne sufferers with oily skin. Since rosacea patients are particularly prone to symptom flare-ups after sun exposure, they may want to look for a high SPF rating in their sunscreen. It typically takes some experimentation and consultation with a dermatologist to find the right combination of cleansers, moisturizers, sunscreens, and cosmetics.

Fragile Nails Should be Pampered

Fingernails are designed to protect delicate fingertips. However, nails don’t do this job well when they split, peel, crack, or chip. Brittleness in nails can have both internal and external causes. Even something as simple as prolonged, frequent exposure to water can weaken nails. Old age, hormonal imbalances, low iron levels, chemical exposure, and other factors can also play a role in making nails brittle. This doesn’t just affect the cosmetic appearance of fingernails. If a nail chips too far, it can expose the tender nail bed. This is very painful and healing can take quite a while since the nail must grow back out to cover the exposed area.

The AAD suggests avoiding harsh detergents, prolonged soaking in water, and alcohol based hand sanitizers. Hand washing should, of course, be practiced to maintain good hygiene. However, it should be done using gentle hand soap and hands should be thoroughly dried afterward. Thick, oil-based creams and ointments should be applied frequently to keep moisture in the nails so that they flex instead of cracking under pressure.

A diet with sufficient amounts of high-quality protein is also beneficial for promoting healthy nails. A dermatologist may be able to recommend other dietary changes including the use of supplements to boost nail (and hair) health. Any changes in diet will take some time to show up in the nails, so this is not a quick fix.

Persistent Fungal Infections

Another reason to see a dermatologist about nail problems is because some highly treatable conditions may linger indefinitely until the correct medication is administered. This is the case with funguses that start growing under the fingernails or toenails. Here, even the most powerful over-the-counter anti-fungal creams do little good. They simply aren’t designed to penetrate to where the fungal infection is occurring. So, an oral medication may be prescribed to get rid of the fungus once and for all. Again, because nails grow slowly, the healing process can take many months. This is one more reason not to delay seeking professional help for a persistent nail problem.

In Office Treatment

The traditional in-office microdermabrasion treatment uses powdered aluminum oxide crystals to buff away dead skin cells. The size of the crystals determines the depth of abrasion achieved. The powder is sprayed against the facial skin through the tip of a hand held wand. Once the desired level of abrasion is achieved, the powder and dead skin cells are vacuumed off the skin using the same wand device. The whole process takes about 20-30 minutes. Some discomfort is normal during the treatment of sensitive areas on the face. However, there should be no pain if the procedure is done correctly. There may be some redness and irritation after treatment. Patients who have particularly sensitive skin or who are experiencing an active acne breakout may not be ideal candidates for this skin resurfacing therapy.

Materials such as baking soda or salt may be used in lieu of aluminum oxide crystals depending on the specific skin problems being addressed. Some dermatologists use a powder-free device with a diamond tip to perform microdermabrasion. This is a new type of machine. Not all physicians agree on whether it is an improvement over older methods or just another equally effective option.

At Home Microdermabrasion Treatments

There are many exfoliating products advertised as microdermabrasion kits for home use. They don’t perform as effectively as professional grade equipment. Multiple treatment sessions are required to achieve noticeable results. With home-use devices, the crystals are mixed into a cream base. Then, this cream is applied to the skin either by hand or using a sponge applicator. Fancier kits have the sponge attached to a motorized device that rubs the cream into the skin for deeper exfoliation. Using the microdermabrasion gel too often, rubbing too hard, or using it on sensitive skin can cause irritation.

The goal of this treatment is to cause spider veins and other small varicose veins to become less apparent. Asclera isn’t approved for treating large varicose veins for medical purposes. It is intended for cosmetic improvement of the blood vessels just under the skin. At this time, it is recommended for treatment of faulty veins in the legs – although some dermatologists may experiment with using it to address spider veins in other areas of the body.

Scientific Evidence

In a clinical study published in June of 2010, Asclera performed favorably in comparison with sodium tetradecyl sulfate (STS) – a similar vein treating agent. Both performed much better than a placebo solution injected into control patients. At the 26 week mark after treatment, 84% of patients reported satisfaction with the treatment using Asclera versus 63% for STS and just 16% for the placebo.

Potential Complications

Some patients did experience adverse reactions at the site of their injections. These were described as mild to moderate. According to the FDA, side effects of treatment commonly include bruising, pooling of blood, discomfort and discoloration. Rare but serious (even fatal) complications have been reported including extreme allergic reactions. Because of this, patients with a known allergy to polidocanol are not considered candidates for treatment with Asclera. All patients are monitored for a period immediately after treatment to verify that they will not have an unforeseen allergic reaction.

Errors on the part of the physician administering the injection can also cause problems. For example, if the drug is accidentally injected into an artery instead of a vein, this can cause tissue death. If the medication is inadvertently injected into the surrounding tissue, it can cause severe pain. This may be resolved with injection of a local anesthetic such as adrenaline. Patients should select a dermatologist or vascular specialist who has extensive experience with spider vein treatment protocols to avoid these mistakes.

Light Chemical Peels

An acid peel can be performed at home using a gentle, over the counter formula at low concentrations. Or, it can be done in a dermatologist’s office or a spa with a slightly stronger solution (up to 30%). There are two main categories of acid used in these treatments. Alpha hydroxy acids (AHAs) such as glycolic acid are naturally occurring chemicals found in plant and animal products. These acids are water soluble and penetrate just the top layer of dead skin, detaching it from the healthy skin beneath so the damaged cells can be rinsed away. Mild irritation, redness, and dryness may result from this treatment and last for a couple of days.

Beta hydroxy acids (BHAs) are often synthetic and include such well known chemicals as salicylic acid – the active ingredient in many topical acne therapies. In higher concentrations, this acid acts as a chemical peel. BHAs are soluble in both oil and water. This makes them a preferred formula for oily skin since the solution has an easier time penetrating deep into the clogged pores. Redness and post-treatment irritation are somewhat less frequent with BHA peels as opposed to AHA peels because the beta hydroxy acid has mild anti-inflammatory properties.

Additional Treatment Details

With both types of chemical peel, the treatment lasts 20 minutes or less. No bandaging or antibiotics are required after a gentle peel because the skin damage is minimal. Serious complications are very rare. However, because the treatment is so light it usually takes several sessions for patients to see a noticeable difference in their skin. Also, the use of a high level SPF sunscreen is mandatory for 2-3 months after each session; the acid treatment makes the skin photosensitive. Unwanted pigment changes may occur with unprotected sun exposure.

What Issues Does This Treatment Address?

The term “periorbital” refers to the area of the face around the eyes. The skin below the eyebrows and on the eyelids is very delicate. It tends to begin showing signs of age earlier than the rest of the face. These effects may include drooping, wrinkling, and photoaging (sun damage). The goal of laser treatment in this area is to tighten the skin, reduce age spots, and smooth out wrinkles. Lasers are thought to produce these effects by promoting the generation of increased amounts of collagen in the skin tissue. One important factor measured by the Italian study was the treatment’s ability to raise the eyebrows. Lifting the brow away from the eyelid reduces the appearance of drooping skin. The degree of lift for patients treated with periorbital fractional laser rejuvenation was slight but detectable (at least 1-2 millimeters). So far, the patient follow up process is showing that the results tend to last for some time.

Treatment Procedure Overview

The patients’ eyes were protected with a metal shield and the skin being treated was coated with a topical anesthetic. Upper and lower eyelids and crow’s feet creases at the corners of the eyes were all targeted for treatment. A low power setting was selected for each patient’s initial session with the option to use a higher setting for subsequent sessions if needed. On average, patients only underwent 2 sessions 3-4 weeks apart. Most reported feeling no discomfort at all. No patients described their pain level as more than “tolerable”. Downtime after the procedure was 24 hours with some swelling and redness lasting for several more days. Post-procedure, patients were given a topical anti-biotic ointment to apply for 3-4 days. 85% of patients receiving the fractional laser treatment reported their results as “very good”. For individuals who do not yet require the extensive rejuvenation provided by blepharoplasty, this is a potential stop gap treatment that dermatologists may begin recommending.