14 minute read
Addressing Peri-Genital Hyperpigmentation
The evolution of gynaesthetics
In recent times, I have seen an exploding interest in aesthetic care and treatment for the intimate area. Google Trends from 2022 show hundreds of thousands of monthly searches for related conditions, which I find hardly surprising.1 We live in the age of the internet, which I believe has three particular areas of relevance here: 1) Traditionally awkward or uncomfortable questions can be asked and answered in the (relative) privacy of your web browser and phone screen 2) Social media and chat culture promotes comparison and discussion of areas previously considered private or even taboo 3) Hand in hand with these, sexuality has become subject to more open-minded consideration and discussion, and has become a key area of individual self-expression and development There are many superficial downsides to this, including increased comparison, rising insecurities and acceptance issues (of self and others).2,3 But the truth is that just like a person’s face, the intimate area has always been a key aspect of who people are, both with themselves and other people. The difference is that today, people are generally more empowered to change the aspects of themselves which they are not comfortable with or want
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to improve. Whilst this could be perceived as being undertaken for male pleasure, in fact I find that women come to me for help with confidence. Men may also wish to have treatment for similar indications, however this is outside the scope of this article. Our role as aesthetic practitioners is to help our patients actualise those decisions. Gynaecological practice covers physiology and pathology of all aspects relating to primary and secondary sexual characteristics, with the ‘intimate area’ generally referring to that subset of genital and peri-genital areas: vaginal, vulval, inguinal, perineal, perianal and the proximal inner thighs.4,5 This area has historically been the territory of the gynaecologist. Sexual health is incredibly complex and important, incorporating puberty, sexual disease and disorders, contraception and pregnancy, before extending to management and quality of life delivery in Addressing menopause and older age. There is an argument that the aesthetics of the intimate area should be an extension of normal gynaecological Peri-Genital care, but in my opinion, we should consider the clear separation of obligatory clinical treatments and those that are elective, bringing us into the realm of aesthetics.6 The Hyperpigmentation first aesthetic interventions were surgical – principally the labioplasty, which was first described medically in the 1970s, and then in 1984 as a cosmetic procedure.7 These interventions have become more and more prevalent Dr Loredana Nigro shares her expertise on since their publicisation in popular culture in the early treating the intimate area with a minimally 2000s, and require the specific skill set and support of plastic surgeons.8,9 invasive approach The past two decades have seen the development and growth of a plethora of minimally- or non-invasive techniques in aesthetic treatments. Almost all of these are applicable to the intimate area, such as chemical depigmentation peels, botulinum toxin, mesotherapy, laser, radiofrequency, platelet-rich plasma and fillers. This goes hand in hand with a need for a general treatment approach which has understanding, setting and meeting patients’ hopes and expectations for the most personal part of their own body at its core. Pigmentation in the intimate area
Aesthetic practice and techniques can be directly applied to the peri-genital area, as the same broad aetiologies apply to its conditions, wherever on the body it may be located.10 However, an understanding of the female intimate area is needed to be able to apply for vaginal rejuvenation. Hyperpigmentation (dark lesions), matrix disfunction and connective tissue breakdown (loss of elasticity, wrinkles and lack of volume), vascular insufficiency and loss of skin tone all apply, and a range of aesthetic techniques can be utilised to help. The peri-genital area is prone to hyperpigmentation because it is replete with melanocytes (the cells that generate pigmentation), with density of up to 2,400 per square millimetre – the highest of any area of the body.11 The tissues of the area are also densely populated with sex hormone receptors, which have been demonstrated to regulate (and particularly upregulate) baseline
Before After
Figure 1: 38-year-old patient 45 days post single treatment plus homecare regime. Before After
Figure 2: 44-year-old patient 45 days post single treatment plus homecare regime.
melanogenesis through activation of the non-classical receptors such as GPER and PAQR7.12 The physiological regulatory pathway is the mechanism behind gestational pigmentation such as chloasma and the linea nigra (the ‘mask’ and ‘line’ of pregnancy), and is a significant aetiological factor for peri-genital hyperpigmentation linked to puberty, birth control, pregnancy and menopause.13 In addition to the physiological propensity of intimate tissues to dyspigment because of the high expression of both melanocytes and sex hormone receptors, the area is also subject to a set of adjunctive environmental factors which are experienced by a large proportion of the population due to their grooming and clothing regime.14,15 Hair removal has become the norm. Waxing, heat and energy-based treatments have all been demonstrated to contribute to post-inflammatory hyperpigmentation.17 Moreover, although shaving is generally disregarded as benign, it in fact triggers a continuous inflammatory process resulting from regular microtrauma.18 Tight clothing and exercise also contribute to friction and the direct inflammatory stimuli which cause and increase intimate hyperpigmentation. The environmental factors which commonly aggravate pigmentation, in conjunction with normal ageing, stress and hormonal imbalances, can cause these tissues to weaken, structurally and functionally, which can lead to aesthetically undesirable outcomes, as well as loss of sexual function, desire and confidence. The good news is that the growth and advancement in minimally-invasive aesthetic treatments has broad applicability to patients’ intimate concerns.
Emerging treatments
There are a myriad of treatments with peri-genital applicability, but they can be broadly split into five categories:
1. Applied cosmeceutical – this includes multi-action peels which have a variety of effects, including skin tightening, direct depigmentation and modulation of melanogenic pathways to control ongoing pigmentation.18 These treatments are generally safe, low impact and efficacious.19,20
2. Injectables – these include a range of intradermal substances introduced with a hypodermic needle, cannula or specialised device. These may be cosmeceutically active sera, as used in mesotherapy, or structural fillers, which are typically cross-linked hyaluronic acid of specific, appropriate viscosity. Mesotherapy has applications for treatment of dyspigmentation, but also the introduction of rejuvenating components to improve skin tone, viscosity and regenerative function.21 Fillers can be used to improve the condition of the general extracellular matrix of the vaginal mucosa using a tracing technique, or to structurally augment the clitoris and g-spot to improve female sexual function.22
3. Neuromodulators – botulinum toxin has demonstrated efficacy in the direct treatment of vaginismus and other conditions.23
4. Energy-based – a variety of energy-based treatments (including lasers, high intensity focused ultrasound and radiofrequency stimulation) are used to generate controlled damage/inflammatory stimuli, triggering the body’s own rejuvenating processes in a controlled and optimised way.24
5. Clinical supplementation/application – this can provide the required micronutrients for healthy tissue maintenance and regeneration, and also stimulate and upregulate the relevant biochemical pathways associated with their maintenance.
Case studies
Patient 1 is a 38-year-old woman with Fitzpatrick skin type III. She exercises regularly, including cycling, spinning and road running. Throughout her 20s she used depilatory creams and shaved frequently. She noticed progressive darkening of the peri-genital area and became concerned about the aesthetics of the condition,
and coincidentally reported acanthosis nigricans and darkening of the elbow. This progressed to the point where the patient sought professional clinical aesthetic assistance for the specific condition. In Patient 1’s case, the likely aetiology appeared to be a combination of general age progression (possibly including hormonal factors) along with chronic low level inflammatory factors from grooming and tight clothing. Patient 2 is a 44-year-old woman who presented with post-pregnancy melasma of the face, which is a frequent complication of pregnancy. This was successfully treated with a medium depth peel, and after that positive result, the patient admitted to similar concerns about darkness in the intimate area, which had worsened significantly during the pregnancy. The primary cause in Patient 2’s case was likely to have been the hormonal fluctuations of pregnancy, possibly with some adjuvant environmental factors. As is the case with dermatological peels, the treated skin needs to be healthy at the time of treatment: that is to say free of infections, rashes and burns (including sunburns). As this is an external treatment there is no specific indication for a gynecological assessment. An adequate history and visual examination is all that is required. For both of these patients, I recommended that a chemical peel would be the best treatment option for them because peels are the best mechanism to deliver combination treatments to deal with pigmentation in a way that is suitable for this area. I recommend in this case a full stack peel which includes combination acids to stimulate rejuvenation and additional ingredients such as vitamin C and retinol to clear existing pigment and improve tissue condition, as well as tyrosinase inhibitors and copper chelators to control repigmentation. It’s also useful from a patient confidence perspective to have a formulation that is approved for on-label use in this area. The type of peel I choose in my clinic is the Dermamelan intimate, a version of the Dermamelan Peel specially configured for use in the peri-genital area and CE approved, which follows three stages:
1. Pre-treatment assessment and preparation which involves assessment of the patient for suitability and contraindications, and administration of antiviral prophylaxis if required (e.g. in the case of history of recurring herpes simplex). 2. An intensive clinician-supervised, in-clinic application of the Dermamelan Intimate peel and mask, after covering sensitive mucosal areas with a protective gel. Post-application, the area is covered with a crystal fibre soothing mask and left to act for four hours, after which it is simply washed off in the shower.
3. Follow-up treatment with topically applied products to regulate skin rejuvenation and pigment production. The formulation is compounded into a liposomal topical delivery suspension, and works through three main effect arms: depigmentation, anti-inflammation and antiageing.
The tailored composition of Dermamelan Intimate is also designed to support optimal function of the peri-genital skin, including rejuvenation of the extracellular matrix to support normal connective tissue function. The tissue-firming and condition-improving effects in both patients can be clearly seen, along with depigmentation efficacy of the product (Figure 1-2). In my experience, side effects are rarely reported. It is extremely well-tolerated and the treatment area is amenable to therapeutic intervention if required. There are normally only very mild transient local symptoms such as redness or mild swelling, which resolve after 72 hours. The treatment of the existing pigmentation is permanent at the point of treatment, and the progression of any future dyspigmentation will depend on the environment and clinical condition (and lifestyle) of the patient. Typically, if required, treatment could be repeated at an interval of three to five years given a normal maintenance routine.
Creating awareness
Intimate pigmentation is a common, chronic condition, exacerbated by environmental and hormonal factors, which can cause significant distress. The raised profile of the issue, and the ability to borrow and customise safe and predictable treatments from general aesthetics, has led to safe, regulator-approved, on-label treatments for effective, predictable remediation. It is important for all practitioners to have an in-depth knowledge of the female intimate area and anatomy before conducting these treatments, as well as specific training.
Dr Loredana Nigro has evolved a practice in aesthetic medicine for more than a decade, specialising in antiageing and bioidentical hormone therapy. A special interest in pigmentation has naturally led to an area focus on gynaesthetics, which is an exciting new subspecialty in the aesthetic industry. Qual: MBBCh (WITS)
VIEW THE REFERENCES ONLINE! AESTHETICSJOURNAL.COM
BOCOUTURE® is the only toxin that can be transported and stored prior to reconstitution without the need for cold chain1–3
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Bocouture® (botulinum toxin type A (150 kD), free from complexing proteins) 50/100 unit vials*. Prescribing information: M-BOC-UK-0432. Please refer to the Summary of Product Characteristics (SmPC) before prescribing. Presentation: 50/100 units of Clostridium Botulinum Neurotoxin type A, free from complexing proteins as a powder for solution for injection. Indications: Temporary improvement in the appearance of moderate to severe upper facial lines (glabellar frown lines, crow’s feet lines, horizontal forehead lines) in adults ≥18 and <65 years when the severity of these lines has an important psychological impact for the patient. Dosage and administration: For intramuscular use only. Unit doses recommended for Bocouture are not interchangeable with those for other preparations of botulinum toxin. BOCOUTURE should only be administered by an appropriately qualified healthcare practitioner with expertise in the treatment of the relevant indication and the use of the required equipment, in accordance with national guidelines . The intervals between treatments should not be shorter than 3 months. Reconstitute with 0.9% sodium chloride. Glabellar Frown Lines: Total recommended standard dose is 20 units. 4 units into 5 injection sites (2 injections in each corrugator muscle and 1 injection in the procerus muscle). May be increased to up to 30 units. Injections near the levator palpebrae superioris and into the cranial portion of the orbicularis oculi should be avoided. Crow’s Feet lines: Total recommended standard dosing is 12 units per side (overall total dose: 24 units); 4 units injected bilaterally into each of the 3 injection sites. Injections too close to the Zygomaticus major muscle should be avoided to prevent lip ptosis. Horizontal Forehead Lines: The recommended total dose range is 10 to 20 units; a total injection volume of 10 units to 20 units is injected into the frontalis muscle in five horizontally aligned injection sites at least 2 cm above the orbital rim. An injection volume of 2 units, 3 units or 4 units is applied per injection point, respectively. Contraindications: Hypersensitivity to the active substance or to any of the excipients. Generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome). Infection or inflammation at the proposed injection site. Special warnings and precautions: It should be taken into consideration that horizontal forehead lines may not only be dynamic, but may also result from the loss of dermal elasticity (e.g. associated with ageing or photo damage). In this case, patients may not respond to botulinum toxin products. Should not be injected into a blood vessel. Not recommended for patients with a history of dysphagia and aspiration. Caution in patients with botulinum toxin hypersensitivity, amyotrophic lateral sclerosis, peripheral neuromuscular dysfunction, or in targeted muscles displaying pronounced weakness or atrophy. Bocouture should be used with caution in patients receiving therapy that could have an anticoagulant effect, or if bleeding disorders of any type occur. Too frequent or too high dosing of botulinum toxin type A may increase the risk of antibodies forming. Should not be used during pregnancy unless clearly necessary. Should not be used during breastfeeding. Interactions: Concomitant use with aminoglycosides or spectinomycin requires special care. Peripheral muscle relaxants should be used with caution. 4-aminoquinolines may reduce the effect. Undesirable effects: Usually, undesirable effects are observed within the first week after treatment and are temporary in nature. Undesirable effects independent of indication include; application related undesirable effects (localised pain, inflammation, swelling), class related undesirable effects (localised muscle weakness, blepharoptosis), and toxin spread (very rare - exaggerated muscle weakness, dysphagia, aspiration pneumonia). Hypersensitivity reactions have been reported with botulinum toxin products. Glabellar Frown Lines: Common: headache, muscle disorders (elevation of eyebrow). Crow’s Feet Lines: Common: eyelid oedema, dry eye, injection site haematoma. Upper Facial Lines: Very common: headache. Common: hypoaesthesia, injection site haematoma, application site pain, application site erythema, discomfort (heavy feeling of frontal area), eyelid ptosis, dry eye, facial asymmetry, nausea. For a full list of adverse reactions, please consult the SmPC. Overdose: May result in pronounced neuromuscular paralysis distant from the injection site. Symptoms are not immediately apparent post-injection. Legal Category: POM. List Price: 50 U/vial £72.00, 50 U twin pack £144.00, 100 U/vial £229.90, 100 U twin pack £459.80. Product Licence Number: PL 29978/0002, PL 29978/0005 Marketing Authorisation Holder: Merz Pharmaceuticals GmbH, Eckenheimer Landstraße 100,60318 Frankfurt/Main, Germany. Date of Preparation:August 2021. Further information available from:. Ground Floor Suite B, Breakspear Park, Breakspear Way, Hemel Hempstead, Hertfordshire, HP2 4TZ Tel: +44 (0) 333 200 4143
Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard for the UK. Adverse events should also be reported to Merz Pharma UK Ltd at the address above or by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.
*Botulinumtoxin type A, purified from cultures of Clostridium Botulinum (Hall strain)1 References: 1. BOCOUTURE® (incobotulinumtoxinA) Summary of Product Characteristics. Merz Pharmaceuticals GmbH. 2. Vistabel® (onabotulinumtoxinA) Summary of Product Characteristics. Allergan Ltd. 3. Dysport® (abobotulinumtoxinA) Summary of Product Characteristics. Ipsen Ltd. M-BOC-UK-0451 Date of Preparation: March 2022
