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VOLUME 6/ISSUE 2 - JANUARY 2019

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Dr Kieron Cooney advises on successful treatment options for stretch marks

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Special Feature: Skin of Colour

Practitioners outline dermatologic concerns and treatment options for skin of colour

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Treating Acne in Pregnancy

Dr Jane Leonard provides an overview on how she treats acne in pregnant patients

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13/12/2018 09:08 Complication Claims

Law firm partner Emma Galland discusses types of patient claims and how to manage them


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Contents • January 2019 06 News

The latest product and industry news

16 On the Scene

Out and about in the specialty

18 News Special: Lip Filler Complications

Aesthetics asks practitioners for their views on the results of two recent reports indicating high numbers of lip filler complications

Special Feature: Dermatologic Concerns in Skin of Colour Page 23

20 First-class Clinical Education

A look at the free clinical education available at ACE 2019

CLINICAL PRACTICE 23 Special Feature: Dermatologic Concerns in Skin of Colour Practitioners discuss their treatment approaches for darker skin types 29 CPD: Treating Striae Distensae

Dr Kieron Cooney presents an overview of successful treatment options for stretch marks

35 Introduction to Drug-induced Photosensitivity

Dr Sandeep Cliff and medical student Nikita Cliff-Patel explain how to recognise photosensitivity and manage medication

40 Advertorial: HA-Derma Leading the way in hyaluronic acid innovation 43 Acne in Pregnancy

Dr Jane Leonard provides an overview of the best-suited treatments to address acne vulgaris in pregnant patients

47 Treating the Cupid’s Bow

Mr Jeff Downie and Mr Mark Devlin provide an introduction to treating the upper lip and explore how to achieve safe, successful results

51 Understanding Periocular Dystonias

Mr Daniel Ezra and Dr Michelle Ting explore the diagnosis and treatment of periocular dystonias

57 The Role of Vitamin C in Skin Health

Dr Helen Robertshaw and clinical educator Victoria Hiscock discuss the science and benefits of topical vitamin C

61 Abstracts

A round-up and summary of useful clinical papers

IN PRACTICE 63 Capitalising on Celebrity Trends

PR and communications consultant Julia Kendrick shares how, when and why to get on board with celebrity trends

66 Building Success in Aesthetics

Business coach Alan Adams presents his step-by-step protocol for building success for your clinic

68 Approaching Complication Claims

Law firm partner Emma Galland advises how to deal with different types of complication claims from patients

71 In Profile: Dr Vishal Madan

Dr Vishal Madan reflects on his career in dermatology and shares advice on how to make the most of an aesthetic practice

72 The Last Word

Independent nurse prescriber Frances Turner Traill argues that all aesthetic nurses should hold a prescribing licence

NEXT MONTH • IN FOCUS: Male Special • Non-surgical rhinoplasty • Website content and SEO

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Clinical Contributors Dr Kieron Cooney is a Cambridge graduate of medicine and a Fellow of the Royal College of General Practitioners. He is an associate member of BCAM and has been awarded a distinction MSc Master’s Degree in Medical Aesthetics from Queen Mary’s University. Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation. Nikita Cliff-Patel is a fourth-year medical student with a passion for evidence-based medicine. She has completed her intercalated BSc in international health and has recently returned to clinical medicine at Leeds Medical School. Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bioidentical hormones. Dr Leonard achieved a first-class honours degree in Anatomical Sciences, specialising in head and neck. Mr Jeff Downie is a consultant oral and maxillofacial surgeon who has a specialist interest in facial aesthetic and reconstructive surgery. He practises facial surgery in Glasgow and his NHS sub-speciality is facial deformity and post-traumatic facial reconstruction. Mr Mark Devlin works as one of three cleft lip and palate surgeons in Scotland and is also a consultant maxillofacial surgeon. He is based at both the Royal Hospital for Sick Children and the Southern General Hospital in Glasgow. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital and Honorary Associate Professor at the UCL Institute of Ophthalmology in Central London. Mr Ezra runs a private practice based on Harley Street and at Moorfields. Dr Michelle Ting is a senior ophthalmology registrar at Moorfields Eye Hospital. She has a strong interest in oculoplastic surgery and works closely with Mr Daniel Ezra. Dr Helen Robertshaw is a consultant dermatologist, Mohs surgeon and director and owner of Southface Skin Clinic, based in Dorset. With 20 years’ experience in dermatology, Dr Robertshaw offers dermatology guidance in skincare and treatments. Victoria Hiscock has been teaching advanced skincare to dermatologists and aesthetic doctors for almost 15 years. She completed her NVQ in beauty therapy 16 years ago, specialising in skin health and has a passion for cosmetic science.

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Editor’s letter The Aesthetics Awards will now seem like a distant memory, along with all the Christmas parties and celebrations, but before you knuckle down and set off on a new year journey, relive the excitement in our special Awards supplement included with this journal! Amanda Cameron The evening was spectacular and a huge Editor success, there were many fabulous outfits and I just adored Russell Kane; he really did his research delivering very topical humour on the night! Thank you for your donations to the British Red Cross; we raised £2,400 which will go towards helping the crisis in Yemen. Now it’s onwards to ACE 2019 which is earlier this year, at the beginning of March, so make sure you book your place on the Elite Training Experience! This year promises to deliver some new and exciting technology, with 3D anatomy innovation in the Dalvi Humzah Aesthetic Training session and lots of practical advice and live demos in all others. The free clinical and business agendas offer something

for everyone, covering a whole host of relevant and interesting topics – we try hard to cover everything that may help you grow your businesses. You can read more about the clinical agenda on p.20. January is our dermatology issue and we are taking a look at some very interesting topics concerning skin, including a Special Feature on dermatologic concerns in skin of colour on p.23, a great CPD on stretch marks, which are notoriously difficult to treat, on p.29, as well as photosensitising drugs on p.35 and acne in pregnancy on p.43. If you are still feeling in need of a bit of glamour (some stardust after the Awards!) then PR consultant Julia Kendrick can help by exploring how, when and why to get on board with celebrity trends and how to translate this into meaningful business opportunities. We at Aesthetics will continue to offer the best educational articles throughout 2019, as well putting on some unmissable events with ACE and the Awards. If there’s anything you would like to learn about this year then please let us know by emailing editorial@aestheticsjournal.com.

Editorial advisory board

We are honoured that a number of leading figures from the medical aesthetic community have joined the Aesthetics journal’s editorial advisory board to help steer the direction of our educational, clinical and business content Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with over 20 years’ experience. He is an international presenter, as well as the medical director and lead tutor of Medicos Rx. Mr Humzah also runs the multi-award winning Dalvi Humzah Aesthetic Training courses. He is a founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow.

Dr Raj Acquilla is a cosmetic dermatologist with more than 12 years' experience in facial aesthetic medicine. In 2015 he won the Aesthetics Award for Aesthetic Medical Practitioner of the Year and in 2012 he was named Speaker of the Year. Dr Acquilla is a UK ambassador, global KOL and masterclass trainer in the cosmetic use of botulinum toxin and dermal fillers.

Sharon Bennett is chair of the British Association of Cosmetic Nurses (BACN) and the UK lead on the BSI committee for aesthetic non-surgical medical standards. She is a registered university mentor in cosmetic medicine and currently a second year student on the Northumbria University Masters course in non-surgical cosmetic interventions. Bennett has been developing her practice in aesthetics for 25 years.

Dr Tapan Patel is the founder and medical director of PHI Clinic. He has more than 16 years’ clinical experience and has been performing aesthetic treatments for more than 14 years. Recently, he was listed in Tatler’s Top 30 Anti-Ageing Experts. Dr Patel is passionate about standards in aesthetic medicine and ensures that along with day-to-day clinic work he also attends and speaks at numerous conferences.

Mr Adrian Richards is a plastic and cosmetic surgeon with 12 years of specialism in plastic surgery at both NHS and private clinics. He is a member of the British Association of Plastic and Reconstructive Surgeons (BAPRAS) and the British Association of Aesthetic Plastic Surgeons (BAAPS). He has won numerous awards and has written a best-selling textbook.

Dr Maria Gonzalez has worked in the field of dermatology for the past 22 years, dividing her time between academic work at Cardiff University and clinical work at the University Hospital of Wales. Dr Gonzalez’s areas of special interest include acne, dermatologic and laser surgery, pigmentary disorders and the treatment of skin cancers.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She is currently undertaking her Masters in Aesthetic Medicine, for which she is also a course mentor. Partridge is a founding board member of the British Association of Cosmetic Nurses and has represented the association for Health Improvement Scotland.

Dr Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multiaward winning EUDELO Dermatology & Skin Wellbeing in London. She lectures in the Division of Cosmetic Science and has published more than 100 scientific articles, book chapters and abstracts. Dr Williams is also author of Amazon-No-1 Bestseller ‘Future Proof Your Skin’.

Dr Christopher Rowland Payne is a consultant dermatologist and internationally recognised expert in cosmetic dermatology. As well as being a co-founder of the European Society for Cosmetic and Aesthetic Dermatology (ESCAD), he was also the founding editor of the Journal of Cosmetic Dermatology and has authored numerous scientific papers and studies.

Dr Souphiyeh Samizadeh is a dental surgeon with a Master’s degree in Aesthetic Medicine and a PGCert in Clinical Education. She is the clinical director of Revivify London, an honorary clinical teacher at King’s College London and a visiting associate professor at Shanghai Jiao Tong University. Dr Samizadeh frequently presents at international conferences and is passionate about raising industry standards.

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Nurses

Talk #Aesthetics Follow us on Twitter @aestheticsgroup #Diploma Sharon Bennett @sharonbennettskin Two awards in 48 hours! Delighted to receive my Post Graduate Diploma in Cosmetic Intervention yesterday @northumbriauni. Leading the way in this specialist area are @BACNurses #Debate Marc Pacifico @marcpacifico Lots of debate (and coffee!) at today’s @thebaaps Council meeting. Many topics discussed including #patientsafety #regulation #filler #medicaleducation #conference @plastauk #bapras #psychology and more! #Teaching Fleur Nicholls @fleur_skinconsultant Change of teaching scenery today at the fabulous Champneys Academy! Discussing the exciting worlds of aesthetics and plastics surgery industries to their talented students! #SafetyFirst Nicky Robinson @nickyrobinsonaesthetics Wise elf... he has found the emergency guidelines in my clinic. Always be prepared and maintain skills as a medical practitioner. #basiclifesupport #anaphylaxis #midwife #alwaysbeprepared #safety #safetyfirst #aesthetics #nmcregistered #bacn #International training Dr Raj Acquilla @RajAcquilla Wow #China that was an incredible show @Allergan #CMAC2018 #Botox #Juvéderm #LIVE now finally home for #Christmas with my family! #ChristmasParty Sherina Balaratnam @MissBalaratnam Thank you to our patients for all your support this year, our partner suppliers for making our events informative and enjoyable, and to my team for making our Christmas event last night a success! #aesthetics

BACN announces new bursary programme The British Association of Cosmetic Nurses (BACN) has launched a new bursary programme supported by UK distributor Church Pharmacy. The bursary scheme will offer financial support to BACN members wishing to undertake a broad range of education, CPD and specialist training. Sharon Bennett, BACN chair and nurse prescriber said, “We have spoken for many years about developing a bursary scheme and with the support of Church Pharmacy, we are now able to do this.” Zain Bhojani, managing director of Church Pharmacy, added, “A huge part of our business involves aesthetic nurses, and this is another way in which we as a company are showing our continuing commitment to nurses working in aesthetics.” The bursary programme will be overseen by the new Education and Training Committee. The BACN will announce finer details on this at the end of January. Complications

ACE Group launches emergency helpline The Aesthetic Complications Expert (ACE) Group has launched an emergency helpline for its members. The helpline aims to provide assistance to practitioners who are in need of immediate advice when experiencing an urgent complication, such as a vascular occlusion or an acute visual impairment. According to the ACE Group, the emergency helpline call is directed to one of 10 practitioners who are internationally recognised and highly experienced in the management of complications. Co-founder of the ACE Group, Dr Martyn King, said, “We are thrilled to launch this much-needed service for our members. The ACE Group Emergency Helpline will aim to assist practitioners in serious situations to help ensure patient safety.” For non-urgent advice, or where there is no immediate danger to the patient, practitioners are encouraged to obtain help from the ACE Group forum, via the website or by email. Other updates from the ACE Group in 2019 will include a change in membership to full and associate members, e-learning modules and national workshops for complication management. Partnership

John Bannon partners with Sinclair Pharma Medical aesthetic supplier in the UK and Ireland, John Bannon, has partnered with pharmaceutical company Sinclair Pharma. As part of this partnership, John Bannon will distribute Sinclair Pharma’s range of products throughout the UK and Ireland, including Silhouette Soft, Ellansé and Perfectha. Sinclair Pharma brand manager Joanna Neal, commented, “Sinclair Pharma is delighted to be working with John Bannon across our entire product range. It comes at a particularly good time for Sinclair Pharma as we have recently launched back into the Irish market with the appointment of Sinead Foran as our aesthetic account manager based in Dublin.”

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Needleless treatments

Vital Statistics

Needle-free injection technology launches UK aesthetic distributor The Smart Group has released a new device that aims to provide a solution to patients with a needle phobia. According to AnxietyUK, up to 10% of the population have a fear of various types of injections, which may prevent many patients from seeking aesthetic treatments. The Med-Jet is a hand-held device that acts as a pain-free delivery system for treatments such as botulinum toxin, platelet-rich plasma (PRP), mesotherapy and dermal fillers, which otherwise require the use of needles or cannulas. According to The Smart Group, the Med-Jet provides a fast, accurate delivery of product through the use of a patented low pressure delivery system. The volume of product and pressures are adjustable, enabling practitioners to target either intradermally, subcutaneously, or intramuscularly. Aesthetic practitioner Dr Vincent Wong, who has been using the device on his patients, said, “The Med-Jet needle-free injector is revolutionary. I am amazed by how easy it is to administer traditional injectables such as botulinum toxin and dermal fillers without using any needles. And my patients love that it is pain-free too!” Kevin Eley, regional director of The Smart Group, added, “Med-Jet is probably the most impressive product I have seen in the last 10 years in aesthetics. Whether it be for the delivery of anaesthetic for painful treatments or for pain-free mesotherapy, toxin, filler or PRP application, it will open up new treatment avenues and market opportunities for practitioners because they can now treat patients who are needle phobic.” Training

Aesthetics Media to host webinar with Galderma

Breast augmentation continues to be the world’s most popular cosmetic procedure with 1,677,320 being performed across the world in the last 12 months (ISAPS, 2018)

Male hair removal from the chest has risen from 15% in 2016 to 30% in 2018 and hair removal from the underarms has risen from 16% to 42% (Mintel, 2018)

Over 51% of smartphone users have discovered a new company or product while conducting a search on their smartphone (Google, 2018)

Women accounted for 86.4% of cosmetic procedures in 2017, whereas men accounted for 14.4% (ISAPS, 2018)

A report in 2018 showed that Instagram Stories now has 400 million daily users, whereas Snapchat has 191 million (Snap Inc, 2018)

Aesthetics Media Ltd, which produces the Aesthetics journal, organises the Aesthetics Conference and Exhibition (ACE) and Aesthetics Awards, has launched a new webinar service. The first webinar will be on January 25 in association with pharmaceutical company Galderma, the manufacturer of the Restylane dermal filler portfolio. Consultant oral and maxillofacial surgeon Mr Jeff Downie, alongside consultant maxillofacial and cleft lip and palate surgeon Mr Mark Devlin will begin the webinar, where they will discuss the anatomy of the smile. The webinar will also feature a lip injection demonstration by aesthetic nurse prescriber Jackie Partridge and a talk on how to build your business with a smile by Professor Bob Khanna. Access to the two-hour webinar will be free; for more information, go to aestheticsjournal.com/news/galderma-webinar-details.

A study amongst 2,147 British adults suggested that 54% who have ever experienced acne feel that it has had a negative impact on their selfconfidence, whilst 22% feel it has affected their social interactions (BAD, 2018)

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Events diary 31st Jan – 2nd Feb 2019 IMCAS Annual World Congress, Paris www.imcas.com

4th-6th April 2019 Aesthetic & Anti-aging Medicine World Congress, Monte Carlo www.amwc.2019conference.org

8th-10th May 2019 37th Annual Conference of the British Medical Laser Association, London www.bmla.co.uk/bmla-conference-2019

14th May 2019 British Association of Sclerotherapists Annual Conference, Windsor www.bassclerotherapy.com

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Injections

GTI Cannula released by Sterimedix The GTI Cannula, a grooved tipped injection cannula, has been developed by aesthetic manufacturer Sterimedix in association with plastic and reconstructive surgeon Mr Olivier Amar. According to Sterimedix, the grooved tip disrupts higher density scar tissue, releasing the surface indentation. The filler or fat can then be injected as the cannula is withdrawn to support the skin surface during healing. The GTI Cannula can be used for the treatment of fine lines and small scars on the face by using a subcision technique, the company explains. Richard Walker, head of sales and marketing at Sterimedix, said, “The device provides a simple and safe method for the treatment of facial scars or skin defects, avoiding the use of a sharp needle or blade. It is a unique cannula tip configuration that is not available anywhere else for a brand new application for aesthetic cannulas.” The GTI Cannula is exclusively distributed by Sterimedix and is manufactured in the UK. Skincare

1 & 2 MARCH 2019 / LONDON

1st – 2nd March 2019 The Aesthetics Conference and Exhibition, London www.aestheticsconference.com

Business development

AestheticSource expands Aesthetic distributor AestheticSource has recruited a dedicated in-house customer concierge team to support recent growth and facilitate its customer base. The new customer-focused team will work solely across the AestheticSource brands, aiming to promote brand and product knowledge alongside strong customer relations. In addition to the new customer care team, AestheticSource has moved to a new head office location in Bedford’s Priory Business Park. Lorna McDonnellBowes, founder of AestheticSource, commented on the recent developments, “Our brands continue to grow, including the launch of three new brands within the past twelve months, a new dedicated in-house customer concierge team, an additional three team members, as well as our recent move to larger head office premises. We recognise that the aesthetic market is evolving and we ensure that our services are flexible and adapted to meet changing needs.”

iS Clinical launches five Skin Condition kits Skincare company iS Clinical has launched five new regime kits that aim to offer patients an affordable, comprehensive 12-week regime with usage guidance that is easily understood and followed by patients to treat different skin conditions. Each iS Skin Condition kit has a cleanser, treatment serum, specific hydration and protection formula allowing a pre-defined, tailored regime for the patient, according to the company. Alana Chalmers, founder of Harpar Grace International, the exclusive UK distributor of iS Clinical, said, “Our skin condition kits are pregnancy safe, botanical, pharma-grade hydroquinone-free and offer a very comprehensive and price competitive regime designed to see visible differences in a 12-week period. The in-kit guidance card and simple four-step process is designed to maximise compliance and offer the practitioner a ‘go to’ solution for skin conditions.” Counterfeits

MHRA seizes counterfeit dermal fillers The Medicines and Healthcare products Regulatory Agency (MHRA) has seized £2 million worth of counterfeit medicines and medical devices as part of Operation Pangea, an initiative involving 116 counties. Products that have been seized include unlicensed dermal fillers, diazepam and modafinil. As well as property raids, the team in charge of Operation Pangea has also targeted websites that offer ‘falsified and unlicensed medical products’. Alastair Jeffrey, MHRA head of enforcement, said, “Criminals who sell medicines over the internet have absolutely no regard for health and taking medicine which is ether falsified or unlicensed puts patients at risk of serious harm.”

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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ACE 2019

Free clinical Symposiums to be held at ACE 2019 1 & 2 MARCH 2019 / LONDON WWW.AESTHETICSCONFERENCE.COM

COUNTDOWN TO ACE 2019 FREE CLINICAL AGENDAS

An exciting, brand new Symposium agenda will take place at the Aesthetics Conference and Exhibition (ACE) 2019 on March 1-2. The agenda will feature four in-depth, two-hour clinical sessions presented by expert speakers from top aesthetic companies on the most relevant topics to medical aesthetics today. Speakers will discuss their latest tips, techniques and treatment advice, while performing live demonstrations showcasing successful results. The UK and Ireland distributor of IBSA Italia, HA-Derma, will host one Symposium, while aesthetic manufacturer Teoxane UK has confirmed two sessions. New sponsors have also been announced for other free clinical agendas at ACE 2019; Enoura, BioActive Aesthetics, and Cutera Medical Ltd will be showcasing their latest products and innovations at the Expert Clinic, while Galderma UK and Church Pharmacy will provide top speakers at their Masterclasses. The Symposiums will take place at the Business Design Centre in London and attendees will receive a plethora of free education and can collect 2 CPD points per Symposium. Seating is allocated on a first come, first serve basis and delegates are encouraged to arrive early to guarantee a seat. For more information and to attend for free, visit aestheticsconference.com. Weight loss

John Bannon Pharmacy launches obesity training Medical aesthetic supplier John Bannon Pharmacy has introduced a new course aiming to provide an introduction to the development of obesity and the consequences and health risks resulting from this condition. The course is called Obesity Management for Aesthetic Practitioners and is run through a partnership between the College of Contemporary Health and John Bannon Pharmacy. According to course designer and pharmacist Iain Ashby, the course will also help to develop preventative strategies and solutions for aesthetic practitioners looking to work in weight management. It will discuss products such as Saxenda, a prescription weight loss medicine. Ashby said, “As the first course available from the new John Bannon Pharmacy Training Academy, which has just launched, I felt obesity management would make an ideal subject due to both its health implications, lack of NHS services, and the ability of aesthetic practitioners to market a private weight management service from their practice.” The course provides 10 hours of accredited CPD and is delivered through podcasts, video, and e-learning units so that it can be seamlessly fitted into a busy life and work schedule, according to John Bannon Pharmacy.

On March 1 and 2, the Aesthetics Conference and Exhibition (ACE) 2019 will play host to 29 clinical workshops that are all free to attend. Ranging from half hour Expert Clinic sessions, to one hour Masterclasses and two hour Symposiums, led by skilled aesthetic practitioners, the educational workshops will offer valuable advice and guidance on everything you need to know to grow your aesthetic practice. You can attend the sessions that suit your learning needs most – whether that involves injectable procedures, laser treatments, skincare approaches or body contouring methods. In addition to the knowledge you will gain and networking opportunities available, 1 CPD point is awarded for every hour of learning! FREE EXHIBITION As an ACE 2019 delegate, you will be able to meet more than 80 of the top suppliers within aesthetics. Whether you’re looking for your next injectable product, skincare range or energy device, the 2,500m2 Exhibition Floor will have you covered! You will also be able to liaise with leading service providers, offering support with insurance, finance, marketing and PR, training and so much more! WHAT DELEGATES SAY

“Great variety and interesting topics” Aesthetic doctor, Oxfordshire

“The content of the sessions was very good and I have taken many useful tips from different speakers” Aesthetic nurse, Newcastle

REGISTER FREE TODAY AESTHETICSCONFERENCE.COM

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Scotland regulation

HIS publishes first clinic inspection reports The regulator for independent healthcare services in Scotland, Healthcare Improvement Scotland (HIS), has published its first inspection reports of independent clinics, following the introduction of mandatory registration in April 2017. Currently, more than 300 independent clinics across Scotland have successfully completed the registration process, according to HIS. The first four inspection reports published were for Dermal Clinic, Dr Lynn Aesthetics, Sage Aesthetics and Fresh Inc Medi-Spa. Alastair Delaney, director of quality assurance at HIS said, “It is crucial that we provide assurances for the public that procedures are carried out in safe and regulated environments. Our work helps to assure those who choose to use independent clinics that they can do so safely.” Stretch marks

Fusion GT releases new stretch mark treatment Aesthetic distributor Fusion GT has introduced a new device that aims to improve the appearance of all types of stretch marks as well as cellulite and scars. The company claims the Biodermogenesi uses a powerful and unique combination of electromagnetic energy and vacuum technology that allows for an increase in oxygenation, rebuilding type three collagen, removing toxins and restructuring the damaged cells within the skin. According to Fusion GT, the product also fills in the stretch mark’s hollow area session by session, which then allows the natural tanning process to occur. Dr Alexander Bader, who was one of the first aesthetic practitioners to have access to the treatment in the UK, said, “Biodermogenesi is a highly effective treatment method for all kinds of stretch marks. With the Biodermogenesi method, we can straighten the rough skin and by improving melanocytes in the treated area we help stretch marks gain colour even in the late-term marks.” According to Fusion GT, patients are required to undertake six to nine treatments to achieve maximum results. Training

IAPCAM to hold second cadaver masterclass The International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM) will hold its second cadaver workshop on January 26 at King’s College London. The one-day workshop will consist of interactive lecturers and a fresh frozen cadaver workshop that will aim to help delegates understand how to rectify complications and how to use hyaluronidase. Teaching at the workshop will be consultant oral and maxillofacial surgeon Mr Jeff Downie, aesthetic practitioner and founder of IAPCAM Dr Beatriz Molina and consultant trauma and orthopaedic surgeon Mr Ansar Mahmood.

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BACN UPDATES A roundup of the latest news and events from the British Association of Cosmetic Nurses

NEW MANAGEMENT COMMITTEE At the last BACN Annual General Meeting, held on December 10, the BACN said farewell to longstanding BACN Board Members Frances Turner Traill and BACN Vice Chair Andrew Rankin. Andrew and Frances have been instrumental in positive developments for nurses working in aesthetics, and have worked tirelessly in regards to regulations both in Scotland, where Frances is based, and within the UK as a whole. They will be sorely missed. The BACN is excited to welcome Clare Amrani, Michelle Mclean and Corrine Hussain to the board, where they will be working alongside existing Board Members Sharron Brown, Anna Baker, Mel Recchia, newly elected Vice Chair Sharon King, and Sharon Bennett, who remains as BACN Chair. The next board meeting will be held this month and outline objectives for 2019.

EDUCATION AND TRAINING COMMITTEE The BACN Education and Training Committee meets for the first time on January 14. This new Committee will focus on: 1. BACN Education and Training Policies and services 2. The development of a new BACN Competency Framework and career structure for the ‘Specialist Aesthetic Nurse’ 3. Management of the BACN/Church Pharmacy Bursary Awards Scheme The new Committee will be jointly chaired by BACN Board Members Anna Baker and Mel Recchia. If any members would like to get involved contact Sarah Greenan, BACN operations manager at sgreenan@bacn.org.uk.

AESTHETICS AWARDS The BACN would like to congratulate all BACN members who were finalists, Commended, Highly Commended and, of course, Winners at this year’s Aesthetics Awards. It was a brilliant event to be a part of, with highlights included longstanding member Jane Laferla winning The Teoxane Award for Aesthetic Nurse Practitioner of the Year, and BACN Chair Sharon Bennett being awarded The Schuco Aesthetics Award for Outstanding Achievement in Medical Aesthetics. This column is written and supported by the BACN

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Dermatology

Study indicates skin cancer rates higher than expected Data from the newly established UK skin cancer database has suggested that there are more than 350% more instances of cutaneous squamous cell carcinomas (cSCC) every year in England than previously thought. cSCC is the second most common form of skin cancer and the research, which was published in JAMA Dermatology, revealed that there are more than 45,000 cSCC every year in England. It also highlighted that a higher risk of cSCC was associated with being older, male, white, and of lower socioeconomic deprivation. Professor Irene Leigh of Queen Mary University of London, lead author of the study, said, “Due to their frequency, the healthcare burden of squamous cell carcinoma is substantial, with high-risk patients requiring at least two to five years’ clinical follow-up after treatment and patients often developing multiple tumours. With poor three-year survival once cSCC has metastasised, earlier identification of these high-risk patients and improved treatment options are vital.” This is the first set of data released from the UK skin cancer database, with more to be published soon, according to the British Association of Dermatology. Nurses

First cohort graduate with PGDip in Cosmetic Intervention The very first group of practitioners studying to get their Postgraduate Diploma Professional Non-Surgical Aesthetic Practice at Northumbria University have graduated. Nurse prescriber and BACN chair Sharon Bennett, said following her graduation, “I am thrilled. The huge workload on top of our normal day-today clinic work and commitments was difficult; however, to gain this recorded university qualification is incredibly fulfilling. The course itself has made me look more deeply at my, already good, knowledge base. The academic work required was demanding, but hugely satisfying.” Training

Cosmetic Courses to offer facial contouring training Aesthetic training provider Cosmetic Courses has introduced a new training course in facial contouring that will launch in February. According to Cosmetic Courses, the training aims to provide delegates with an up-to-date holistic approach to facial assessment, where they will learn how to define, enhance and sculpt the jawline, chin and cheeks. Both needle and cannula techniques will be covered in the one-day course, which will be based in the Buckinghamshire, London and Nottingham locations on a monthly basis. Clinical lead at Cosmetic Courses, Dr Fiona Durban, said, “Here at Cosmetic Courses we are always keeping up-to-date with trends and offering training courses according to the market and delegate requirements. This course is specific to areas covering facial contouring and is a step beyond older style courses that offer teaching in ‘face lift’ techniques. Different products, both toxin and filler, will be combined to optimise results.”

60

Iveta Vinklerova, director of HA-Derma You’ve made an impact on the UK market in a relatively short period of time. What’s behind your success? Here at HA-Derma, we have been persistent in passing our market and product knowledge onto our practitioners. Our aim is not to just sell product, but to focus on helping practitioners maximise their treatment outcome through first-hand training. We are very proud of our strategy ‘train first – treat after’, regardless of the experience the practitioner may have. This has helped us to promote our product manufacturer IBSA Pharmaceutici Italia’s ‘global anti-ageing strategy’ and deliver the company’s unique concept of ‘curing the wrinkles’ instead of just fixing them. Positioning Profhilo® as a third injectable option alongside toxins and dermal fillers has worked particularly well, as patients are now seeking the treatment themselves. Through our in-depth specialist training, we are helping practitioners to recognise that not all lines have to be treated with only toxin or dermal fillers. How do you see the future of hyaluronic acid (HA) in aesthetics? The innovative use of HA in non-surgical injectable treatments is the future with patients seeking solutions and treatments that offer dual benefits – both an immediate physical benefit/ result, alongside an accumulative skin health improvement. Profhilo has altered the traditional injectable portfolio – what is the next best thing? We consider ourselves fortunate to be working with a company like IBSA as it is really a leader in HA innovation. We have just launched another innovative injectable product – Viscoderm Hydrobooster, which filled a gap in the practitioner portfolio to treat dynamic lines and skin quality. Since the official launch recently, enquiries have not stopped coming into our office with training fully booked until March. The plan for 2019 is to extend the current injectable portfolio even further, but for that you need to watch this space. This column is written and supported by

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Microvibration

endoSPHÈRES Therapy range expands Italian manufacturer Fenix Group has launched the Eva facial device, to add to the existing endoSPHÈRES Therapy range, a three phase non-surgical treatment that uses three applicators. According to the company, phase one uses sensorised ablative microvibration (SAM) that focuses on the deep cleansing of the skin and exfoliates; phase two uses compressive microvibration that improves circulation, plumps and renews skin; and phase three uses a vibro electro delivery (VED), which facilitates the transmission of active ingredients into the tissue using modulated electric square-wave pulses. Chantal Merighi, director of the Fenix Group UK said, “The Endospheres technology used in the Eva Facial device delivers lasting results without needles and with no downtime. We consider this an evolution in skin wellness, it has a universal action on the process of skin renewal as a red carpet treatment or part of an advanced facial routine.” The product is distributed exclusively through the Fenix Group UK. Training

Harley Academy becomes recognised by IQ Verify Aesthetic training provider Harley Academy has achieved certification to become the first recognised IQ Verify learning provider in the aesthetic medicine sector for skin rejuvenation. The IQ Verify scheme has been developed in accordance with ISO standards, which are internationally recognised to ensure that products and services are safe, reliable and of good quality. The scheme provides a pathway for healthcare and non-healthcare professionals to progress from Levels 4-7 in skin rejuvenation. Mark Salt, IQ Verify director and general manager said, “Harley Academy has worked really hard to achieve this standard. As it is internationally recognised and accepted, it demonstrates they have achieved the benchmark for delivering aesthetic services, in particular, skin rejuvenation.” Complications

Save Face releases new customer complaints statistics Independent accreditation body Save Face has published its consumer complaints audit report for 2017-2018. The results indicated that in the last twelve months, Save Face received 939 patient complaints and concerns; 934 were in regards to non-Save Face registered practitioners and five were registered with the accredited body. Dermal filler treatments accounted for the highest amount of complaints at 616, and botulinum toxin treatments resulted in 224 complaints. The report concluded that outcomes from the last year resulted in one landmark conviction (resulting in imprisonment for one doctor who caused three individuals to suffer an anaphylactic shock after injecting them with counterfeit Botox), 94 refunds, 27 insurance claims and 19 legal cases. To find out more about the latest Save Face statistics, go to p.18.

Aesthetics aestheticsjournal.com

News in Brief HA-Derma receives Award from IBSA UK and Ireland distributor of IBSA Italia, HA-Derma, has been presented with the IBSADERMA Excellence Profhilo Game Changer 2018 award in recognition of their outstanding contribution towards the Profhilo brand. Iveta Vinklerova, director of HA-Derma stated, “We have been focused on a very specific approach to grow the Profhilo brand in the UK and it’s amazing to learn that the strategy also had an impact globally, driving brand awareness and demand.” BAS announces 2019 speakers Speakers for the British Association of Sclerotherapists (BAS) 2019 conference, taking place on May 14 at Dorney Lake Conference Centre near Windsor, have been confirmed. Delegates will hear talks from vascular surgeon and phlebologist Dr Marianne De Maeseneer, nurse prescriber Emma Davies, consultant vascular surgeon Mr Ian Franklin and consultant vascular and endovascular surgeon Professor Andrew Bradbury. For the full agenda, visit the BAS website. Med-fx updates website Aesthetic and skincare product supplier Med-fx has launched an updated version of its website to improve customer experience. David Tweedale, head of Medfx, commented, “This is the first stage of a number of changes we are looking to make at Med-fx to improve the experience for our current and new customers. Over the coming months, we will be rolling out more initiatives to improve our customer service levels and make Med-fx a true partner to all aesthetic practitioners.” Hamilton Fraser launches annual survey Hamilton Fraser Cosmetic Insurance has released a survey to gain information regarding what educational materials would be most useful for aesthetic practitioners, such as workshops, academic courses and conferences. Naomi Di-Scala, aesthetic insurance manager of Hamilton Fraser Cosmetic Insurance, said the company is intending to conduct this survey on an annual basis. Esther Fieldgrass launches podcast CEO and founder of EF MEDISPA, Esther Fieldgrass is now the host of a new podcast called The Beauty Biz. Fieldgrass said, “I’ve always wanted to launch a podcast. It’s so interesting to be able to chat to a variety of knowledgeable industry experts about their depth of experience in their chosen field.”

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Patient safety

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Skincare

Industry reps meet with MP about cosmetic procedure safety Aesthetic industry bodies and medical associations attended a roundtable meeting on December 17 with MP Jackie DoylePrice, parliamentary under secretary of state for mental health, inequalities and suicide prevention to discuss standards and safety of cosmetic procedures. The one-hour meeting involved representatives from the GMC, GDC, NMC, the JCCP, BACN, BCAM, BAAPS among others, who informed the minister on the current issues with cosmetic surgical and non-surgical procedures to identify areas for improvement and develop solutions to strengthen safeguards for the public. Among the points covered were concerns surrounding the advertising of offers and social media practice potentially reaching a vulnerable population; location of non-surgical practice, such as backrooms of hairdressers; qualifications of both surgical and non-surgical practitioners; prescribing practice and issues surrounding over-prescribing and prescribing outside the competence of the practitioner. Nurse prescriber Sharon Bennett represented the British Association of Cosmetic Nurses (BACN) as chair and said she was hopeful of the progress made in the meeting. “It’s a positive step and I believe the Minister now has a firmer understanding of what is happening in the aesthetics arena and the problematic issues that we are facing. Patient safety was at the heart of the meeting. There are a some concerns that we discussed that I believe she can address, but there are some that she cannot manage at the moment as legislation is currently not on the agenda.” Professor David Sines, chair of the Joint Council for Cosmetic Practitioners (JCCP) was also in positive spirits following the meeting. He said, “The Minister facilitated a frank and open discussion about patient safety and public protection issues relating to both the surgical and non-surgical cosmetic sector. The importance of raising the public’s level of awareness to safety issues and to promoting best practice in the sector in the interests of public protection was emphasised. The Minister has adopted a positive position in respect of the promotion and dissemination of best practice, including the need to deliver competence-based education and training for all those who practice in the sector.”

Rosmetics introduces peel collection Aesthetic clinic and distributor Rosmetics has launched the VI Peel Collection that aims to provide a solution to skin concerns such as acne, acne scarring, ageing, dull skin and hyperpigmentation. Each kit includes two of every peel. This includes the VI Peel, which is designed to soften hard lines and wrinkles, the VI Peel Purify, that aids in clearing dead skin cells and destroys bacteria, the VI Peel Purify Precision Plus, which aims to smooth and repair scarred and dark areas, the VI Peel Precision Plus, used for brightening, and the VI Peel Precision, which also softens lines and wrinkles, removing rough patches, according to Rosmetics. Clive Shotton, sales director said, “The new VI Peel Collection box gives practitioners the ability to have the entire VI Peel range in a simple and easy to use system. With all the different peels in the one box it is also a cost effective way for the practitioner to hold the stock.” Appointment

Allergan appoints new product specialist for West London Pharmaceutical company Allergan has appointed Lorraine McLoughlin as its product specialist for West London. According to the company, McLoughlin has a real passion for aesthetics after working in the specialty for more than 20 years. Her new role will focus on looking after healthcare professionals providing treatment with Allergan products in her region. McLoughlin said, “I am very excited to be working for the number one trusted market leader and I’m looking forward to sharing my experience and supporting healthcare professionals’ individual needs.” Dermal fillers

Consensus guidelines released for calcium hydroxylapatite Preliminary guidelines for the off-label use of Radiesse (calcium hydroxylapatite – CaHA), for biostimulation in the face and body have been published in Dermatologic Surgery. A global panel of 14 aesthetic practitioners specialising in dermatology, plastic surgery and oculoplastic surgery, including UK practitioner Dr Kate Goldie, convened to develop consensus-based guidelines for treating laxity and superficial wrinkles using diluted (ratio of 1:1) and hyperdiluted (≥1:2) CaHA. The practitioners documented their clinical experience with Radiesse and provided guidelines for its use to stimulate targeted neocollagenesis and act as a biostimulatory agent. They described its use in the face, neck, décolletage, upper arms, lower body, including the abdomen and buttocks, as well as cellulite, stretch marks and the legs. The authors stated, “CaHA appears to promote dermal remodelling through stimulation of collagen and elastin for a skin-tightening effect and to improve superficial wrinkles, elasticity, and skin thickness. Because the evidence in the literature to support this practice is limited at present, this report provides preliminary guidelines for the novel, off-label use of CaHA as a biostimulatory agent in the face and body with the expectation that future rigorous clinical trials will provide further evidence for optimal outcomes.” Radiesse is developed by Merz Pharmaceuticals and is currently FDA approved to correct moderate-to-severe wrinkles and folds, as well as soft-tissue volume loss in the face and hands.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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On the Scene

Training

MATA launches new Postgraduate Diploma Medical and Aesthetic Training Academy (MATA) has introduced a new Postgraduate Diploma in Clinical Injectable Therapies. According to MATA, the qualification will reflect JCCP educational competencies and Cosmetic Practice Standards Authority (CPSA) guidelines and is targeted to new and experienced aesthetic practitioners. The training provider has confirmed that this post-graduate qualification will cover all aspects of aesthetic injectable therapies, requiring delegates to evidence knowledge, clinical skills and understanding in all areas of aesthetic injectables. MATA explains that those who hold the current Level 7 Certificate in Injectables for Aesthetic Medicine or equivalent will be able to credit this towards the Diploma to ‘upgrade’ their qualification. Mr Faz Zavahir, medical director and founder of MATA, said, “MATA is thrilled to take medical aesthetic training to the next level, with the launch of our advanced training qualification now at Diploma level, mapped to the latest guidelines and regulated by the awarding body EduQual.” Regulation

Dangers of medical devices highlighted A recent BBC Panorama programme has highlighted the need for stricter regulations around the use of medical devices in the healthcare sector. The BBC investigation worked alongside the International Consortium of Investigative Journalists and 58 media organisations around the world. It found that medical devices, such as implanted contraceptives, pacemakers and hip replacements, were being put into people after failing in clinical trials. Currently, Europe does not have a governmental body that checks medical devices before introducing them to market, instead a Notified Body (in which there are 58 in the EU) issue CE marks. Approval by just one of them means that they can be used anywhere in the European Economic Area (the EU, Iceland, Liechtenstein and Norway). Mr Dalvi Humzah, consultant plastic, reconstructive and aesthetic surgeon recognises that this is also a issue for the aesthetic sector. He said, “Although a CE mark is helpful the devices and products used in aesthetics rarely undergo formal clinical trials to assess their efficacy in this specialty. What we need is a more rigorous testing of products before and after they enter the UK market.”

HA-Derma International Masterclass, Italy UK and Ireland distributor of IBSA Italia, HA-Derma, invited guests to travel to the Italian town of Pavia for two days of learning on November 15-16. IBSA Italia welcomed practitioners from the UK, Ireland, Belarus, Israel, Lithuania, Spain and Ukraine to their International Masterclass. The two-day programme began with an introduction to IBSA’s product portfolio with the first day dedicated to an update on Aliaxin dermal fillers and technical features of the new Hydrolift technology. Delegates were also able to watch live demonstrations from plastic surgeon Mr Giovanni Salti, aesthetic practitioners Dr Fabio Ingallina and Dr Antonello Tateo, which were moderated by plastic surgeon Mr Giammatteo Cecchini. On the second day, talks on non-surgical rhinoplasty and injectable Profhilo took place, both of which were accompanied by live demonstrations. IBSA also provided talks on the recently launched Viscoderm Hydrobooster. Iveta Vinklerova, director of HA-Derma, said of the event, “The feedback we have received from this masterclass was fantastic and it was immensely satisfying to see the delegates enjoy the education during the two days.” On the Scene

IAAFA Annual Conference & Awards 2018, Windsor The International Academy of Advanced Facial Aesthetics (IAAFA) held its annual conference and awards ceremony at its new location of the De Vere Beaumont Estate in Windsor on November 24. Around 250 delegates attended the two events to learn about the latest techniques, advice and practice from an international faculty. Among the topics covered were bruxism and headaches, threadlifting, clinical record keeping, considerations for dentoskeletal support, technical innovations in facial aesthetics, plasma therapy, perioral rejuvenation and male vs. female aesthetics. Following the conference was a charity dinner and awards ceremony. IAAFA members entered their best patient cases into treatment categories such as challenging botulinum toxin case, lip sculpting, total facial sculpting and best newcomer, among others. The winners included aesthetic practitioner Dr Katie Teiman and dentists Dr Arti Singh, Dr Donna Mills, Dr Chetan Sharma and Dr Christina Cope. President and founder of IAAFA, Professor Bob Khanna, was extremely delighted with the success of this year’s event. “I created IAAFA to unite clinicians and industry leaders from all over the world to harness knowledge, passion and to pass on the latest innovations in this field. IAAFA is like a family and it’s wonderful to not only get everyone together to learn and network, but also to help those in need through the charity.” All proceeds for the conference and awards go to children’s charities such as MakeA-Wish UK. “Our Academy has just celebrated its 13th birthday and I am thrilled to announce that so far we have managed to raise £224,000 in total for children’s charities,” Professor Khanna said.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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On the Scene

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On the Scene

Perfect Eyes Ltd one year anniversary, London

Aesthetic reconstructive oculoplastic surgeon, Mrs Sabrina ShahDesai invited family, friends, colleagues, press, influencers and patients to join her at her Harley Street clinic to celebrate its first-year anniversary. The event took place on November 27 at the Perfect Eyes Ltd clinic, where guests were invited to join Mrs Shah-Desai and her team for drinks and finger food. Nicola Chapman, influencer and writer for Pixiwoo blog, provided ‘Perfect Eyes’ makeup applications for guests, while PCA skincare specialists offered complimentary chemical peel treatments. Mrs Shah-Desai also presented a £5,000 donation to The Akshaya Patra Foundation, which provides children in India with school lunches. Mrs Shah-Desai said of the event, “The last twelve months have shot by and I wanted to host an event to thank all my family, friends and industry colleagues who have been integral and invaluable to my journey this year. The highlights were being able to infuse the event with makeovers from the generosity of Nicole Chapman, a fun photobooth, skin peels and generous goody bags from industry distributors. Feedback has reinforced the event was a success and we managed to host more than 80 people over the four hours our event spanned.”

Indonesian Physicians: DHAT Complications Workshop, London

Practitioners from Indonesia travelled to London especially for a workshop held by Dalvi Humzah Aesthetic Training (DHAT) at the Royal Society of Medicine, London. Led by consultant plastic, reconstructive and aesthetic surgeon Mr Dalvi Humzah, the workshop focused on the management of non-surgical complications and covered those arising from toxin, dermal fillers, threads and laser treatments. Both theoretical and practical management of these areas were discussed during the day. Mr Humzah said the delegates were actively involved in discussing and developing protocols for the management of complications from toxins and dermal fillers. The day ended with an update on the AIIVL Blindness Protocol, discussing the most recent publications on the treatment of blindness. Dr Lidya Barasjid, who attended the workshop, said, “Thank you for providing the opportunity to participate in this very useful workshop. These important learnings will secure a continued quality assurance and customer satisfaction at my clinic.”

On the Scene

Aesthetics Awards 2018, London

Around 800 aesthetic practitioners, clinics, suppliers, training providers, and other industry companies gathered for the prestigious and long-awaited Aesthetics Awards 2018 on Saturday December 1. The Park Plaza Westminster Bridge hotel in central London was transformed into a magnificent, glistening ball room where Winners, Highly Commended and Commended finalists in 26 categories celebrated their achievements for the year. Guests enjoyed a lovely three-course dinner, which was what managing director of Medical Aesthetic Group David Gower

enjoyed most. He said, “My highlight tonight was the chicken – it was fantastic!” Amanda Cameron, the editor of the Aesthetics journal and Aesthetics Awards judge welcomed guests to the ceremony, and this year’s comedian and host, Russell Kane, had the audience in hysterics throughout his 30-minute performance. Julia Langford co-owner of Tay Medispa, the winner of The AestheticSource Award for Best New Clinic, UK and Ireland, said of her evening, “It’s been a brilliant night; Russell Kane was absolutely fantastic and we’ve met some really lovely people too. A great night all round!” Mr Dalvi Humzah, consultant plastic surgeon and founder of Dalvi Humzah Aesthetic Training concluded, “The evening, entertainment and the company has been great, and everyone has been in the spirt to celebrate the end of the year.” To view this year’s winners, go to www.aestheticsawards.com. Entry to the Aesthetics Awards 2019 will open in May and the ceremony will take place in London on December 7.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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also very concerned with the number of practitioners unable to confidently differentiate between the type of complication and adverse event.

Changes in supply and demand King believes that a lot of the complications are due to the ‘supply and demand’ for the popular procedure. She explains, “Lips are an advanced treatment area of the face and a lot can go very wrong, very quickly. People are asking for these procedures all of the time but the quality of injections shouldn’t be compromised just because of the demand.” Dr Molina states that she too is concerned that due to the popularity of the treatment, lips are being taken less seriously. She notes, “A few years ago, lip treatments would be more Aesthetics asks practitioners for their views on commonly performed for corrective measures – we would create a more defined upper lip for an ageing the results of two recent reports that indicate a patient who had lost volume or fill in any wrinkles. Now, there is so much focus on enhancement and high number of lip filler complications volume that we see practitioners pump in more and Last month, not one, but two reports were released on more product when, in actual fact, many of the patients’ faces can’t complications and patient complaints across the specialty. The tolerate that.” first was from independent accreditation body Save Face1 and the second from the Aesthetic Complications Expert (ACE) Group.2 A lack of experience Interestingly, lip fillers trumped any other complication or complaint Both King and Dr Molina recognise that a complication can happen across both reports. The Save Face report was an annual summary at any stage in an aesthetic career, however, believe that those who of patient complaints and concerns regarding 934 practitioners who have had more experience tend to be able to recognise the signs were unregistered with the body and five who were registered with quicker and can intervene to prevent it. Dr Molina says, “Of course Save Face. It was indicated that out of all concerns, there were 616 a complication can arise with 15 years’ experience behind you, but complaints regarding dermal fillers, 72% of which were in relation to the difference that I find is, you can anticipate it much quicker and lip treatments. The most common treatment outcome relating to the sometimes prevent it from happening. An inexperienced practitioner lip complaints, with 163, was swelling and bruising. Whilst 144 people may not notice the complication occurring straight away.” had lumps and nodules, 56 felt they looked worse, 52 thought they King notes that there was a significant correlation between new had an uneven result, 24 had an infection and four reported vascular injectors and complications from the ACE Group data, and although occlusion or impending necrosis.1 she recognises that new injectors are more likely to use the forum The ACE Group runs a Facebook forum where many of those than their more experienced colleagues, she was concerned registered with the group (of which you must be a medical with how ‘new’ the practitioners really were. “The majority of the professional) turn to for guidance, particularly in relation to complications reported from the ACE Group forum were from complications. Nurse prescriber and co-founder of the group Sharon practitioners who are new to the industry, particularly those with King audited its then 1,700 forum members across an 18-month less than 12 months’ experience. Don’t get me wrong, we all had period. She reported 389 filler-related complications, with 207 (53%) to start somewhere, but what I am finding now is that the pathways relating solely to the lips. It stated that 22 of those were obvious into aesthetics are very different. When I first started out, the majority vascular occlusions, 43 practitioners reported bruising and the rest of those going into aesthetics would have had several years’ included complications such as herpes, asymmetry and delayed experience. Nowadays, many people are working in aesthetics part onset nodules.2 It was also noted that 76 of those who posted in time and although they may be experienced in their field they may the forum displayed signs that they couldn’t distinguish between a not be in aesthetics,” she explains. vascular occlusion and bruising. So, what do practitioners think of these statistics and why are we seeing such high numbers in relation Not enough regulation to lip procedure complications? All of the practitioners interviewed also believe the lack of regulation Consultant plastic and reconstructive surgeon Mr Adrian Richards, surrounding products, premises and practitioners are affecting lip who is also the clinical director of training provider Cosmetic complication rates. It was stated in the Save Face report that 83% of Courses, says he is not surprised by these figures. “These figures the treatments reported were carried out by beauticians, hairdressers are not a shock to me. The combination of the popularity of the and lay people (someone who is not qualified in a given profession).1 treatment, the advanced anatomy in this area and the lack of Mr Adrian Richards says, “One of the ongoing concerns in this specialty regulation in the specialty comes as no surprise to me that there is that it isn’t regulated. Although the ACE Group stats are in relation to are problems,” he explains. Both King and aesthetic practitioner medical professionals, we also see a lot of non-medics giving fillers. In and founder of the International Association for Prevention of the UK, dermal fillers are classed as a medical device, not a prescriptionComplications in Aesthetic Medicine (IAPCAM), Dr Beatriz Molina only medicine.3 This can enable those who are not medically trained or were also not alarmed by the figures, for reasons much like the have little experience to have access to it. This is absolutely reflected in above, but emphasise that the figures are far too high. They are the high number of complaints in the Save Face report.”

Lip Filler Complications

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Lips aren’t for beginners When it comes to lip procedures, one may ask, ‘Is there a lack of training in the area?’ All three interviewees agree that lip augmentation training should not be offered to beginners and novice injectors. Both Mr Richards and King, who is also a trainer, agree that practitioners should have had previous injecting experience, in a lower risk area, undertaken basic training and consolidated their learning by treating patients before moving on to areas of greater risk areas, like the lips. King says, “If I train someone on a beginner’s level, I will not be teaching them anything about the lips at all – they need to have a considerable amount of injection experience, obviously it’s dependent on the individual but I’d say around 30-40 procedures. The lips warrant a course in its own right and I won’t teach any other indications during that period.” Mr Richards also believes that the trainers have a responsibility to prevent beginners from going out and injecting when they are clearly not ready. He adds, “All trainees should be assessed as part of their course, someone shouldn’t start injecting just because they have attended. If an assessor doesn’t feel like the practitioner would be safe to inject alone they should advise more training.” He adds that although other forms of training, such as a Master’s degree, for example, may be very beneficial, its essential to get hands-on experience. “The theory is great and they may learn lots about the anatomy, but it is absolutely vital that practitioners have hands-on experience during training; it’s a practical specialty after all. In the Cosmetic Courses Level 7 course, delegates need

to observe 10 dermal filler and 10 toxin treatments and perform the same amount supervised by a trainer. We tend to judge each delegate individually and then tailor their training plan to their specific needs. I believe factors such as these will directly reduce lip complication rates,” he says.

The verdict All the practitioners interviewed were not surprised by the rate of lip complications in the specialty at present. The fact that the procedure is highly popular and is also in a potential danger zone ‘make it prone to problems’, according to Mr Richards. Dr Molina notes that it is a step in the right direction that statistics are being published to highlight the issues so that patients and practitioners alike are aware of the dangers of the treatment. She says, “Reporting a complication is nothing to be ashamed of, no one is pointing the finger, it actually shows that you are taking your job incredibly seriously.” King concludes, “The popularity of lip treatments speaks for itself, but with that being said, so do the complications. It appears to me that those who are seeing the most amount of complications with lip augmentations are those who are new to the specialty. We should tighten up on the training of this particular area to potentially prevent the figures getting any higher than they already are.” REFERENCES 1. Save Face, Consumer Complaints Audit Report 2017-2018 <https://www.saveface.co.uk/wp-content/ uploads/2018/11/Save-Face-Consumer-Complaints-Report-2017-18-FINAL-1118.pdf> 2. Data on file obtained from ACE Group 3. Kilgariff S, Aesthetics journal, ‘Should dermal filler be a POM?’, September 2017 <https:// aestheticsjournal.com/feature/should-dermal-filler-be-a-pom>

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Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Skincare science According to the latest facial skincare market report by intelligence agency Mintel, the women’s facial skincare category is growing year-on-year, but there are signs that patient education could help grow this market, and therefore your profits. Many patients still aren’t knowledgeable about ingredients, and confusion around SPF use remains high. That’s why skincare topics at ACE are so important. These sessions will explore the latest ingredients and products available to maximise patient satisfaction and retention and teach you how to not only use the products effectively, but to also sell them to your patients.

First-class Clinical Education at ACE 2019 Aesthetics looks at the high quality, free education available at the renowned Aesthetics Conference and Exhibition in London Where can you see live demonstrations, top up your CPD points, discover new products and treatments and hear from more than 50 of the most highly respected speakers, all for free, under one roof? The Aesthetics Conference and Exhibition (ACE) 2019, of course! This year, for the first time, there will be three free clinical agendas, all jam-packed full of demonstrations and opportunities to learn the latest on aesthetic injectables, lasers, skincare, chemical peels, regenerative therapies, aesthetic devices and more! So, register for your free pass and make your way to London on March 1-2 to take advantage of these unique, clinical opportunities.

Injectable innovations It’s without a doubt that the number of injectable procedures in the UK, and the world, are on the rise. Therefore, the clinical sessions at ACE this year will have an even larger focus on treatment success, avoiding vascular complications, techniques for both needles and cannulas and promoting patient safety. Packed with live patient demonstrations, you will leave these injectable sessions with new ways to enhance your patients’ natural beauty and overall satisfaction.

“I find the Masterclasses are really good for in-depth knowledge on topics. There were some live models being worked on, and some samples that we could use ourselves, so that was really interesting”

Device developments Have you ever invested in aesthetic devices? From lasers and radiofrequency machines to plasma and microneedling pens, there is so much available. However, the choice of what to invest in can be mind boggling for many aesthetic practitioners. This is why the device sessions at ACE are the place to be if you are thinking of investing for the first time, looking for something new or wanting to upgrade your current technologies. These sessions will discuss the latest developments and innovations in technology and devices, providing you with the confidence you need to invest and the knowledge to maximise patient results.

“The session I attended was fantastic, it was so informative, they discussed all the different products in the range and it was great to see the demonstrations by two of the doctors. Really, really brilliant”

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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ACE 2019 clinical agenda overview

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Get the best experience These topics are just a small taste of what you can get out of your free ACE 2019 pass. As well as our three clinical agendas, you will also gain crucial advice for running your practice from 19 free business sessions. Not only that, but you will meet representatives from more than 80 aesthetic companies, who will show you their newest and most innovative products, as well provide you with free samples and exclusive ACE 2019 show offers. The amount of educational content available, as well as the precious networking opportunities, makes ACE the best conference and exhibition to be at this year.

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However, higher levels of melanin correlate with increased incidence of post-inflammatory hyperpigmentation (PIH), which epidemiological studies have shown occur more commonly in patients with skin of colour.2 Just like with pale skin, PIH in dark skin can develop as a result of any number of causes, including:3 • Infection • Allergic reaction • Trauma (such as a burn) • Disease (such as acne, atopic dermatitis, impetigo) The most common cause of PIH in skin of colour is acne, with up to 65% (239) of African-American patients developing acne-induced PIH, suggested one 2002 study.4 Around half of Hispanic (52.7% – 55) and Asian (47.4% – 19) patients included in the study reported PIH as a result of acne. PIH occurs when inflammation or damage to the skin results in increased production of melanin, which is what gives skin its colour. “In our skin, we have two main types of cells: keratinocytes and melanocytes, the latter being the pigment-producing cells,” explains Dr Kluk, adding, “In pigmentary conditions, Journalist Allie Anderson explores common melanocytes pass increased amounts of pigment to conditions that affect patients with skin of the other cells – the keratinocytes.” Thus, melanin colour and how they can be treated synthesis is propagated.5 Aesthetic practitioner Dr Ifeoma Ejikeme attests that pigmentary conditions In previous years, it is fair to say there has been a lack of are particularly troubling for patients with skin of colour, not widespread acknowledgement of the vastly different skincare just because they are more common, but also because the requirements in patients with skin of colour. Thus, the beauty pigmentation tends to be more pronounced and longer lasting.1 and aesthetic industries alienated a huge proportion of their “The most concerning aspect is not necessarily the pigmentation customer base. Thankfully, things have moved forward. From the itself, but how dark it is and how long it remains,” she says, adding high-street chemist to the high-end clinic, individuals with skin that her experience has shown that, “In darker skin, the areas of from Fitzpatrick phototypes I through to VI can access products hyperpigmentation can be present for anything from six weeks to and treatments for their individual concerns, which often vary four months.” greatly according to how dark their skin is. “While we see certain conditions more commonly than others Melasma in people with skin of colour, it’s important to recognise that any Another pigmentary condition that is more prevalent in darker skin complaint can affect any skin colour,” points out consultant skin2 – particularly Fitzpatrick phototypes IV to VI3 – is melasma, dermatologist Dr Justine Kluk. “Recognition of skin conditions which occurs when the melanocytes in the skin produce too much in skin of colour can be more difficult for clinicians who are only melanin. While the exact reason why this happens is unknown, used to looking after individuals with white skin – and therein it is associated with increased exposure to the sun’s ultraviolet lies the first challenge,” she adds. In discussing dermatologic rays, and female hormone activity. The latter is evidenced by an concerns in skin of colour, it can be helpful to use the Fitzpatrick increased incidence of melasma in pregnant women (hence, it is skin phototype scale to classify patients’ skin. Dr Justine Hextall, sometimes referred to as a ‘pregnancy mask’), and those taking also a consultant dermatologist, suggests that ‘skin of colour’ is oestrogen-containing medication, such as the contraceptive pill usually categorised as Fitzpatrick types III to VI. and hormone replacement therapy.7

Dermatologic Concerns in Skin of Colour

Pigmentary skin conditions Post-inflammatory hyperpigmentation “There are notable differences in skin disease incidence, presentation, and treatment based on skin type,” Dr Hextall explains, noting, “This includes structural and functional differences in the skin and hair, for example. In darker skin, increased levels of melanin and larger melanosomes – but the same number of melanocytes – provide greater photoprotection, resulting in a lower incidence of skin cancers.”1

Melasma presents as small freckle-like spots or larger brown patches, usually with symmetry and an irregular border, on the face. Dr Hextall points out that there are three main patterns of melasma:8 1. Centrofacial – where pigmentation occurs on the cheeks, forehead, upper lip, nose and chin 2. Malar – where pigmentation is present only on the cheeks and nose 3. Mandibular – where pigmentation is seen on the ramus of the mandible (jawbone)

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Before

Image courtesy of Adonia Medical Clinic

After

Before

Image courtesy of Adonia Medical Clinic

After

Image courtesy of Adonia Medical Clinic

Figure 1: Various angles before and seven weeks after using the full Obagi Nu-derm System kit. Images courtesy of Dr Ifeoma Ejikeme at Adonia Medical Clinic.

Treating pigmentation disorders in skin of colour In patients with PIH, it’s crucial to ensure the cause of the inflammation is addressed in the first instance, according to Dr Hextall. She says, “There is no point in treating pigmentation if there is active acne, for example. Likewise with eczema, switching off the inflammation is crucial, as is finding suitable emollients to maintain the skin barrier and help to reduce recurrence.” According to the practitioners interviewed, similar methods are used to treat both melasma and post-inflammatory hyperpigmentation, and the first-line treatment is typically a tyrosinase inhibitor. Tyrosinase is an enzyme produced by melanocyte cells, and is a crucial component in melanin synthesis. Consequently, by restricting the activity of tyrosinase, the skin makes less pigment,4 making tyrosinase inhibitors effective in combatting hyperpigmentation of many causes. “Tyrosinase inhibitors include arbutin, oligopeptide 68, kojic acid and liquorice extracts,” says Dr Ejikeme, adding, “They vary in potency, but they’ve been shown to regulate pigment, they are safe, and they can be used on an ongoing basis.”2,9 Perhaps the most commonly used tyrosinase inhibitor is hydroquinone. It has been historically shrouded in controversy because of its association with the practice of skin lightening among some cultures that view lighter skin as more attractive. “In some areas of Africa and Asia, where culturally there is sometimes a desire to have fairer skin, hydroquinone is often misused, and people obtain unregulated products on the black market where the dose is unknown,” comments Dr Kluk. Because of this, patients can sometimes be sceptical about the clinical use of hydroquinone, she notes. However, it is widely accepted that, when used with caution and under the supervision of a medically trained practitioner, it is both safe and effective in treating hyperpigmentation, such as PIH and melasma. This is typically a topical preparation containing 2-4% hydroquinone, applied to the affected skin daily for up to four months. Prolonged use can, paradoxically, worsen hyperpigmentation.8 Improved results are often achieved when hydroquinone is used in combination with other ingredients, such as retinoids, antioxidants, glycolic acid and – most importantly – broad-spectrum sunscreen.10 The exact formulation and dose of these ingredients vary between products and have different modes of action in tackling pigmentation. Retinoids (vitamin A) work by increasing cell turnover, explains Dr Kluk. “Our skin is always renewing itself; new skin cells are forming, and old cells are lost from the surface,” she says, explaining, “If you increase cell turnover, the contact time between melanocytes and keratinocytes is shorter, so there is less time for the melanocytes to pass their pigment on to the other cells.” Consequently, the proliferation of pigmentation is reduced, she notes.11

Since retinoids can be irritating to the skin,5 Dr Kluk often suggests patients begin with an over-the-counter topical retinoid, since these contain lower-strength retinoids (typically retinol), which tend to be better tolerated. “If a milder formulation doesn’t help, I would move a patient on to prescription-strength retinoid [tretinoin], since the magnitude of benefit one would expect would be greater,” she says. Antioxidants, namely L-ascorbic acid (vitamin C), have a depigmenting effect by interrupting the key steps of melanogenesis and inhibiting tyrosinase action, resulting in reduced melanin formation.6 L-ascorbic acid also reduces oxidative stress, and has been shown to have antiinflammatory and photoprotective properties.2 Glycolic acid can be effective in treating hyperpigmentation due to its exfoliant effects; it gradually penetrates the uppermost layer of the epidermis and ‘peels away’ skin, including superficial pigmentation patches and dark marks.14 Aesthetic practitioner Dr Amiee Vyas, who has special interest in dermatology, highlights that chemical peels can be effective as a second-line treatment for melasma and PIH. “In conjunction with topicals, I find a course of chemical peels with mandelic and glycolic acid, done with adequate preparation, starting at low strengths and then at regular intervals with a step-wise increase in strength, gives best results,” she says. Chemical peeling agents carry a risk of prolonged hyperpigmentation in Fitzpatrick skin types IV and above and should be used with caution, but some studies have found that peels using a combination of salicylic and mandelic acid are more effective and less likely to yield side effects than glycolic acid peels.15,7

Follicular skin conditions Other skin conditions frequently seen in skin of colour relate to the hair follicles. A particularly prevalent complaint, especially in black skin, is pseudofolliculitis – inflammation caused by irritation secondary to the way in which hair regrows – owing to the thick, coarse and coily properties of African hair.8 “I see this a lot and it’s certainly more common in skin of colour, but it can affect anyone who has curly, thick hair – even Fitzpatrick skin types IV and V,” comments Dr Ejikeme, adding, “A type of folliculitis that is very common in men with skin of colour is pseudofolliculitis barbae, where ingrown hairs lead to chronic inflammation, pigmentation and scarring in the beard area.” She explains that pseudofolliculitis can also affect darker-skinned women with thick, curly hair, in the groin and underarm region. In both cases, the condition develops after shaving (or other forms

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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of hair removal), where the hair has difficulty coming through to the skin’s surface due to its wiriness; when it penetrates the skin, it grows back inwards, causing inflammation.17 “This commonly results in a cycle of infection, papules and pustules, inflammation and pigmentation,” Dr Ejikeme adds. Some follicular skin conditions can be caused by certain beauty practises – such as straightening of afro hair with chemicals, traction or heat – leading to scarring (or cicatricial) alopecia. The most prevalent subtype of scarring alopecia is central centrifugal cicatricial alopecia (CCCA), where hair loss begins in the mid-scalp and extends outwards, is progressive, and – left untreated – can be permanent.9 The Skin of Color Society states that, “Though previously thought to be solely related to the use of hot combs, excessive heat and hot oils on the scalp, chemical relaxers, and excessive tension from braids, tight hair rollers, weaves or extensions, the current thought also points to heredity (family history) playing a role.”19

Treating follicular skin conditions in skin of colour Scarring alopecia treatment is aimed at halting the progression of hair loss, and tends to be limited to anti-inflammatories such as topical corticosteroids, hydroxychloroquine, and the immunosuppressants tacrolimus and ciclosporin.10 “For dermatologic conditions secondary to cultural practises I find patient education will usually resolve concerns, once the practice is stopped,” comments Dr Vyas. Successful treatment of pseudofolliculitis can be difficult, but it will usually subside when the patient stops shaving (or whatever hair removal method they use). However, this is not an option for many people.17 “The definitive treatment of choice, and the only cure for the problem, is to remove the hair permanently, usually with lasers or electrolysis,” says Dr Ejikeme. A number of different types of lasers have been demonstrated to be effective in treating pseudofolliculitis (including pseudofolliculitis barbae), among them long-pulsed neodymium: yttrium aluminium garnet (ND:Yag)18 and pulsed infrared lasers.20 One of the challenges in treating pigmentation in darker skin, Dr Kluk points out, is restricting the treatment to the abnormally pigmented skin without affecting normal skin. “The way pigment lasers work in hair removal, for example, is by targeting pigment in the hair follicle, which is different in colour to the skin,” she says. “It can be very difficult to differentiate between the different shades when treating hyperpigmentation in skin of colour and there is a higher risk of pigmentation worsening as a result of laser treatment.” In fact, hypopigmentation, as well as hyperpigmentation, is a potential side effect of lasers.21 Other treatments include:22 • Topical hydrocortisone to reduce inflammation • Topical acne treatments (benzoyl peroxide and tretinoin), which prevent thickening of the follicular skin • Combined corticosteroid, tretinoin and hydroquinone to tackle inflammation and suppress pigment synthesis • Oral antibiotics to treat infection and inflammation

sometimes under the false impression that they don’t need to use sunscreen because they rarely burn. However, darkening of the skin after exposure to sunlight – which can affect even Fitzpatrick skin types V and VI – is a sign of UV-induced DNA damage.22 The Skin Cancer Foundation suggests micro-ionised physical sunscreen for people with darker skin to avoid the chalky-white appearance, or chemical sunscreen with SPF 15 or above.23 Generally, patients with skin of colour are becoming wiser to the most effective treatment methods, thanks largely to resources like The Black Skin Directory, whose aim is ‘connecting women of colour with expert skincare professionals’.24 As Dr Hextall summarises, the result is that, “With accurate diagnosis and a treatment plan that carefully considers the risk, particularly of post-inflammatory hyperpigmentation, there is no reason this group cannot have safe and successful aesthetic treatments.” REFERENCES 1. Cichorek et al., ‘Skin melanocytes: biology and development’, Postepy Dermatol Alergol, (2013) <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3834696/> 2. Davis E and Callender V, ‘Postinflammatory Hyperpigmentation: A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color’, J Clin Aesthet Dermatol. 2010 Jul; 3(7): 20–31. Accessed at <www.ncbi.nlm.nih.gov/pmc/articles/PMC2921758/> 3. Schwartz R et al., ‘Postinflammatory Hyperpigmentation’, Medscape, May 2018. Accessed at <www. emedicine.medscape.com/article/1069191-overview> 4. Taylor SC et al, ‘Acne vulgaris in skin of color’, J Am Acad Dermatol. 2002 Feb;46 (2 Suppl Understanding):S98-106. Accessed at <www.ncbi.nlm.nih.gov/pubmed/11807471> 2018 5. Ngan V, Postinflammatory hyperpigmentation. DermnetNZ, December 2015. Accessed at <www. dermnetnz.org/topics/postinflammatory-hyperpigmentation/> 6. British Association of Dermatologists, Melasma (patient information leaflet), March 2018.</www.bad.org.uk/for-the-public/patient-information-leaflets/ melasma/?showmore=1&returnlink=http%3a%2f%2fwww.bad.org.uk%2ffor-the-public%2fpatientinformation-leaflets#.XBe-M2j7TIU> 7. Bandyopadhyay D, Topical treatment of melasma, Indian J Dermatol. 2009 Oct-Dec; 54(4): 303–309. <www.ncbi.nlm.nih.gov/pmc/articles/PMC2807702/> 8. Oakley A, Melasma. DermnetNZ, September 2014. <www.dermnetnz.org/topics/melasma/> 9. Pillaiyar T et al, Skin whitening agents: medicinal chemistry perspective of tyrosinase inhibitors. Journal of Enzyme Inhibition and Medicinal Chemistry. 2017, 32:1, 403-425. <www.tandfonline.com/ doi/full/10.1080/14756366.2016.1256882> 10. Grimes P, Management of hyperpigmentation in darker racial ethnic groups. Semin Cutan Med Surg. 2009 Jun;28(2):77-85. <www.ncbi.nlm.nih.gov/pubmed/19608057> 11. Dr Justine Kluk, ‘Understanding Retinol Tolerance’, Aesthetics <https://aestheticsjournal.com/ feature/understanding-retinol-tolerance> 12. NHS, Acne treatment. NHS.uk, April 2016. <www.nhs.uk/conditions/acne/treatment/> 13. Telang P, Vitamin C in dermatology. Indian Dermatol Online J. 2013 Apr-Jun; 4(2): 143–146. <www. ncbi.nlm.nih.gov/pmc/articles/PMC3673383/> 14. Estrela J, Glycolic Acid and Dark Skin, Livestrong.com (undated). <www.livestrong.com/ article/186177-glycolic-acid-dark-skin/> 15. Garg VK, Sinha S, Sarkar R. Glycolic acid peels versus salicylic-mandelic acid peels in active acne vulgaris and post-acne scarring and hyperpigmentation: A comparative study. Dermatol Surg. 2009;35:59–65. [PubMed] 16. Sarkar R et al, Chemical Peels for Melasma in Dark-Skinned Patients. J Cutan Aesthet Surg. 2012 Oct-Dec; 5(4): 247–253. <www.ncbi.nlm.nih.gov/pmc/articles/PMC3560164/> 17. Cunliffe T, Folliculitis and boils (furuncles/carbuncles). Primary Care Dermatology Society, June 2018. <www.pcds.org.uk/clinical-guidance/folliculitis-an-overview> 18. Patterson S et al, Central centrifugal cicatricial alopecia. DermnetNZ, March 2014. <www. dermnetnz.org/topics/central-centrifugal-cicatricial-alopecia/> 19. Heath C et al, Dermatology Education; Central Centrifugal Cicatricial Alopecia (CCCA). Skin of Color Society (undated). <www.skinofcolorsociety.org/dermatology-education/central-centrifugalcicatricial-alopecia-ccca/> 20. Ross E et al, Treatment of pseudofolliculitis barbae in skin types IV, V, and VI with a long-pulsed neodymium:yttrium aluminum garnet laser. JAAD August 2002 (47):2, 263–270. <www.jaad.org/ article/S0190-9622(02)00057-9/abstract> 21. Kauvar A, Treatment of pseudofolliculitis with a pulsed infrared laser. Arch Dermatol. 2000 Nov: 136 (11): 1343-6. <www.ncbi.nlm.nih.gov/pubmed/11074696> 22. Gomez J, Folliculitis barbae and pseudofolliculitis barbae. DermnetNZ, July 2016. <www. dermnetnz.org/topics/folliculitis-barbae/> 23. Saini R et al, How to choose the right sunscreen for your skin type. Skin Cancer Foundation. August 2013. <www.skincancer.org/prevention/sun-protection/sunscreen/choosing> 24. The Black Skin Directory, <www.blackskindirectory.com/>

Protecting skin of colour The most important advice to give to patients is to include a broadspectrum sunscreen as part of their daily skincare routine, and that is no different for patients with skin of colour. People with dark skin are

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Treating Striae Distensae Dr Kieron Cooney presents an overview of successful treatment approaches for stretch marks It is thought that around 70% of women and 40% of men around the world are affected by striae distensae or ‘stretch marks’, correctly termed striae gravidarum if occurred as a result of pregnancy.1-3 But, what exactly are they and can they ever be successfully treated? Striae distensae are dermal manifestations that appear as a result of abnormal and excessive stretching of skin, causing a distorted skin surface appearance that can be permanent.4 For many people, they can be well tolerated and accepted as a normal skin change that is a result of childbirth, ageing or being overweight. However, for many individuals, striae distensae can be a significant aesthetic problem and, at worse, may cause significant physical disfigurement.5 Striae distensae also have the potential to significantly affect an individual’s mental health and quality of life, including a loss of self-confidence, lowered self-esteem and difficulties with sexual relations.5,6 Research has suggested that the buttocks are the most common place for stretch marks to appear in women, with 86% affected at some point in their life.3,5 The abdomen is the next most common area on the body at 48% and thighs follow at 46%.4 Similarly, research also suggests that 85% of men with striae distensae have them present on the buttocks, while 28% have them on their lower back and 25% around the knee area.5 It is also worth noting that there is little evidence that supports any preventative measures for the development of stretch marks. The pathogenesis of striae distensae remains unclear and there are many histopathological theories. These are centred around the understanding that the fundamental trigger for the formation of striae distensae is based on a shearing, tearing trauma to the collagen matrix and dermal tissue.7

• Normal process of growth in adolescence associated with rapid increased size of body areas14 • Elastosis due to mast cell degranulation and stimulation of macrophages12 Classification Striae distensae can be sub-classified according to the age of the damaged tissue.15 Two types of striae distensae are histologically distinct and are completely different in appearance (Figure 1 & 2). The distinction is important, not just in relation to prognosis and appearance, but also in regards to the type of treatment that might be most effective. • Striae rubra is characterised by early onset, immature striae distensae, with inflammatory, erythematous changes. The expected duration of striae rubra is not reported and, similarly, the time for transition into striae alba is indeterminate.16 • Striae alba is the term used to describe the more chronic and permanent form of striae distensae. These are a result of gradual transformation of striae rubra, and are characteristically pale, atrophic, avascular lesions, similar in appearance to stretched, mature, scarred tissue.8,16

Understanding stretch marks The basic histology of striae distensae is similar to that of dermal scarring following trauma. For example, there will be signs of early inflammatory changes, followed by dermal thinning and flattening.8 There are atrophic changes, resulting in the appearance of furrows and ridges, as well as the flattening of rete ridges and loss of collagen and elastin.9 Microscopic analysis of striae distensae reveals disruption of the structure of dermal fibrous tissue and resultant alteration in the mechanical function of the dermis.10 Such changes may be generated through the remodelling forces acting on dermal tissue, which could arise from a variety of factors, including fat tissue expansion and intra-abdominal pressure from rapid weight gain, such as that which occurs in pregnancy.16 It is thought that common risk factors for developing stretch marks are related to family history, pregnancy, obesity, Cushing’s syndrome (a metabolic disorder) and Marfan’s syndrome (a genetic disorder that affects connective tissue).9 Theories of how these changes are induced are inconclusive, but include: • The release of toxins that damage tissue11 • Alteration in the collagen matrix12 • Familial predisposition based on genetic traits13

Figure 1: An example of striae rubra. Typically inflamed with a broad, red and raised appearance.8

Figure 2: An example of striae alba. Pale, atrophic, flattened with a stretched appearance.8

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Treatment Topical treatments There are many creams that aim to help prevent and treat the appearance of striae distensae; many of which are readily available from any high-street cosmetics store. Brennan et al.17 reviewed six studies involving 800 participants looking at topical preparations for preventing stretch marks in pregnancy. The study suggested that there is no significant difference between those women receiving topical preparations with active ingredients, vitamin A, hyaluronic acid or olive oil and cocoa butter compared with placebo creams. Creams containing almond oil, cocoa butter oil, olive oil, wheat germ, and many other natural agents have been recommended for the treatment of stretch marks, largely based on strong marketing strategies, company-based unpublished trials, and anecdotal claims. Although, they have little or no published evidence of efficacy.18-21 Tretinoin The vitamin A analogue tretinoin, which is well known for its benefits in reducing the appearance of facial wrinkles, photodamage and ageing, has been used with some success on striae distensae.22,23 One randomised controlled study used 0.1% tretinoin cream and a placebo cream of similar colour on 26 women with striae rubra daily for 24 weeks. There was a significant improvement in the length and width of striae in women treated at the early onset of development of striae distensae with tretinoin, and women’s self-rating on the appearance of the striae distensae showed marked improvement in the tretinoin group.23 Tretinoin 0.1% cream was also reported to be effective in reducing the appearance of abdominal striae rubra by use of a self-rating score in 26 women using daily applications for three months following the end of pregnancy.22 Despite limited evidence, tretinoin cream 0.1% appears to be a promising option to treat striae distensae in its early stages. Laser treatments Laser is a popular and effective option for the management of many aesthetic skin and dermatological problems and appears to be promising for the management of both striae rubra and striae alba.24,25 The type of lasers most effective for treating striae distensae are those which target the haemoglobin chromophore, which is present within dilated blood vessels of striae rubra.26 Laser treatment of striae distensae results in epithelial damage

Types of laser Pulsed dye laser The 585/595 nm pulsed dye laser (PDL), commonly used for the treatment of superficial vascular lesions on the face, has been shown to have good results in reducing the appearance of striae rubra by its effect on dilated blood vessels within the affected skin.27-29 1064 YAG laser A potentially safer, and more effective option, especially for higher Fitzpatrick skin type patients, is the 1064 nm diode Nd:Yag

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with resultant re-epithelialisation, and stimulation of extracellular collagen synthesis and increased elastin production.26 There is remodelling of the tissue with a resulting improvement of surface appearance, similar to the effects seen with laser treatment of cutaneous scar tissue.26 Lasers that target the water chromophore in skin, such as the ablative 10600 nm C02 laser, and the 2940 nm Er:YAG laser, are widely used in the treatment of acne scars. As such, these lasers are also being used for the treatment of stretch marks, especially striae alba, which have similar histological features as acne scar tissue.8 Striae rubra are particularly vascular and so lasers with a haemoglobin chromophore may be expected to be of particular benefit when treating immature, vascular striae rubra.26 Various lasers are available and which one you chose depends entirely on a case-by-case basis. I believe that the literature indicates that chronic striae alba appears to be more resistant to laser treatment, though ablative and non-ablative fractionated laser devices do offer optimism for future success for those affected. Microdermabrasion Microdermabrasion has been shown to create surface trauma, which triggers re-epithelialisation and dermal collagen stimulation.37 These changes are important in reducing the appearance of scarred and damaged skin surface texture and may help reduce the appearance of stretch marks, for which type it is not defined.38 However, there remains scant evidence of the effectiveness of microdermabrasion in treating striae distensae.39,40 Interest is growing, however, in combining this with other treatment modalities such as chemical peels,41 microneedling,42 tretinoic acid,43 and platelet-rich plasma (PRP).44 Chemical peels Chemical skin peels are caustic chemical substances that are used for many aesthetic conditions such as acne, skin wrinkling, photodamage and ageing. Glycolic acid, salicylic acid, and trichloroacetic acid less than 30% (TCA), are commonly used skin peels. They appear to be safe, popular and effective, and might be considered a useful option for the treatment of stretch marks.41,46,47 Despite the potential for collagen stimulation, dermal regeneration and remodelling, there appears to be a paucity of evidence published on the use of peels for the treatment of striae distensae and results seem marginal.45

laser, with promising results for the treatment of vascular lesions, with minimal absorption by melanin, and hence much less risk of post-treatment hyperpigmentation. In a 2008 study, it was shown to give ‘good’ or excellent’ results on improving the appearance of striae rubra.30 Ablative and non-ablative fractional lasers These lasers, which include the 10600 nm CO2 laser, and the 2940 nm Er:YAG laser, are commonly used for the treatment of scars and have been used with some success for the treatment of striae distensae.31-34

Intense pulsed light therapy Intense pulsed light therapy, (IPL), is a noncoherent polychromatic intense light pulse used for many vascular and pigmented skin conditions. There is evidence of a positive effect of IPL treatment on the appearance of striae distensae, with evidence of neocollagenesis on posttreatment striae distensae biopsies.35 There is a risk of hyperpigmentation using IPL in some skin types, as with many lasers, although IPL has been used successfully for the treatment of striae distensae on all skin types with no reported side effects.36

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Research has suggested that the buttocks are the most common place for stretch marks to appear in women, with 86% affected at some point in their life

One double blind study, using 70% glycolic acid or placebo on women’s thighs for both forms of striae distensae, reported an overall improvement in outcomes of up to 15% over six months’ treatment in 40 women self-reporting their results.46 The treatment of stretch marks using skin peels in combination with other treatment modalities is more optimistic. TCA and salicylic acid peels have been used with tretinoin, microdermabrasion and microneedling on striae rubra, with what I believe to be promising results.41,46,47 However, more research is needed on the use of skin peels alone for striae distensae. Microneedling Microneedling is used in the treatment of acne scars, skin wrinkles, and facial rejuvenation. It is often used in combination with other treatments such as PRP and mesotherapy to facilitate the transdermal delivery of chemical agents. There is only one published study on the use of microneedling on its own for striae distensae and results were encouraging. Histological and observational analysis of the results of 30 women with striae rubra who were treated with three treatment sessions, six weeks apart showed a positive outcome. They analysed microneedling alone versus microneedling with a TCA peel and showed improvement in both groups; albeit more so in the combined treatment group.47 Microneedling is more commonly used in combination with other treatments such as skin peels,47 radiofrequency,48 light therapies49 and PRP.50 Radiofrequency Radiofrequency (RF) is now a commonly used treatment for skin laxity in aesthetics, through its ablative effect on subcutaneous tissue and subsequent contraction and tightening effects.51 Treated areas undergo thermal damage in the deep dermal collagen, which stimulates wound healing, dermal remodelling and new collagen, elastin and hyaluronic acid formation.52 Some studies have looked at the benefits of RF on the appearance of stretch marks and most reported improved appearance of stretch marks after treatment with RF.48,52,53,54 In one study, nano-fractionated RF was applied to 33 women with striae alba on the abdomen or buttocks, over three sessions at four

weekly intervals. It was reported that there was improved appearance after treatment, which was assessed by a blinded photograph assessment, clinical observations and patient feedback.55 RF appears to have a place in the treatment of striae distensae (undifferentiated), and it was reported in a study by Ryu HW et al in 2013 that it may be more effective when combined with other treatment modalities such as laser.48 Research into the use of RF in combination with PRP, microdermabrasion and microneedling is worthy of more consideration as few studies have looked at the benefits on the appearance of stretch marks in combination treatment modalities.50,54,55 PRP PRP is a concentrated preparation of the individual’s platelets prepared from centrifugation of whole blood and extraction of the separated platelet-rich layer. There are many preparation techniques and limited consensus as to the ideal degree of concentration of the platelets for maximal benefit.56 Platelets contain numerous growth factors, such as platelet derived epithelial growth factor and vascular endothelial growth factors, which modulate cell proliferation, angiogenesis and inflammatory responses, with deposition of collagen and stimulation of tissue regeneration.57,58 PRP is now being used in the treatment of acne and non-acne scars and for skin rejuvenation and dermal regeneration. 59-61 There are very few peer-reviewed publications on the use of PRP specifically for the treatment of striae distensae, and they claim at least mild improvement in the appearance of striae alba and rubra.44,65,66 However, these studies were based on subjective outcomes of clinician and patient assessment and are of limited evidence strength.

Discussion There are many treatment options available for the management of striae distensae. However, good evidence of treatment efficacy is limited and so choice of best treatment remains difficult. Many research publications base their conclusions upon weak levels of evidence which may be inherent in this area of aesthetic research. Limitations in conclusive evidence is, in part, a reflection of the difficulties in designing robust Level 1 or 2 research protocols. Inclusion of low numbers of patients, without standardisation of demographics, together with variable end point measurements, limited long-term follow-up, and the use of subjective observational assessment tools, has contributed to there being mostly low strength evidence presented in many papers. The evidence reviewed here, however, suggests that ablative and non-ablative fractional lasers, as well as 1064 diode Nd:YAG and 584 PDL lasers, may be the most effective non-surgical treatment for stretch marks. Results of studies using topical tretinoin cream are also encouraging. Combination treatment modalities such as PRP with RF and microneedling and microdermabrasion appear to be promising. More research, particularly well designed, randomised, blinded, controlled trials, with improved objective end-point measurements, is necessary to elucidate further the efficacy of current treatment modalities. Dr Kieron Cooney is a Cambridge graduate of medicine with the MB BChir certificate and a Fellow of the Royal College of General Practitioners. He is an associate member of the British College of Aesthetic Medicine and has been awarded a distinction MSc Master’s Degree in Medical Aesthetics from Queen Mary’s University in London. He is the Medical Director of Cosmedica Clinics and senior partner at St Helens Medical Centre, both in the Isle of Wight.

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REFERENCES 1. Cho S, Park ES, Lee DH et al. Clinical features and risk factors for striae distensae in Korean adolescents. J Eur Acad Dermatol Venereol 2006; 20: 1108–1113. 2. Osman H, Rubeiz N, Tamim H et al. Risk factors for the development of striae gravidarum. Am J Obstet Gynecol 2007; 196:62.e1–5. 3. Elton RF, Pinkus H. Striae in normal men. Arch Dermatol 1966; 94:33–4. 4. García-Hidalgo L, Orozco-Topete R, Gonzalez-Barranco J et al. Dermatoses in 156 obese adults. Obes Res 1999; 7:299–302 5. Psychological impact of stretch marks and scarring revealed -Thursday 26 August 2010 – Nursing in Practice (Internet). 2010 (26 August). <https://www.nursinginpractice.com/article/psychological-impactstretch-marks-and-scarring-revealed> 6. Yamaguchi K, Suganuma N, Ohashi K. Quality of life evaluation in Japanese pregnant women with striae gravidarum: a cross-sectional study. BMC Res Notes 2012; 5:450. 7. De Angelis F, Kolesnikova L, Renato F, Liguori G. Fractional nonablative 1540-nm laser treatment of striae distensae in Fitzpatrick skin types II to IV: clinical and histological results. Aesthet Surg J 2011; 31: 411–419. 8. Zheng P, Lavker RM, et al. Anatomy of striae, Br J Dermatol, 1985; 112: 185–193 9. Singh G, Kumar LP. Striae distensae. Indian J Dermatol Venereol Leprol 2005; 71: 370–372 10. Devillers C et al. High resolution skin colorimetry, strain mapping and mechanobiology. Int J Cos Science 2010; 32 (4): 241-245 11. Kogoj F. Seitrag zur atiologie und pathogenese der stria cutis distensae. Arch Dermatol Syphiliol 1925;149:667. 12. Sheu HM, Yu HS, Chang CH, Mast cell degranulation and elastolysis in the early stage of striae distensae, J Cutan Pathol 1991; 18: 410–416 13. Jaramillo-Garcia CM, Lopera-Calderon MC et al. Related factors with atrophic stretch marks in adolescent female students from two private educational establishments from the city of Medellin, 1997–1999. CES Med 2009; 23: s69–79 14. Weber FP, Idiopathic stria atrophicae of puberty, Lancet 1935; 229:17. S Kang MD, Topical tretinoin therapy for management of early striae. 1989 (August); 39(2): S90-S92 15. Elson ML. Topical tretinoin in the treatment of striae distensae and in the promotion of wound healing: a review. J Dermatol Treat 1994; 5: 163–165. 16. Watson RE, Parry EJ, Humphries JD, Jones CJ, Polson DW, Kielty CM, et al. Fibrillin microfibrils are reduced in skin exhibiting striae distensae. Br J Dermatol. 1998;138(6):931–7. 17. Brennan M, Young G, Devane D. Topical preparations for preventing stretch marks in pregnancy. Cochrane Database Syst Rev 2012; (11). 18. Moore J, MD Gary Kelsberg, MD Sarah Safranek, MLIS Do any topical agents help prevent or reduce stretch marks? J Fam Pract. 2012 December;61(12):757-758 19. Timur S, Kafkasli A. The effect of bitter almond oil and massaging on striae gravidarum in primiparaous women. J Clin Nurs 2012; 21: 1570–1576. 20. Buchanan K, Fletcher HM, Reid M. Prevention of striae gravidarum with cocoa butter cream. Int J Gynaecol Obstet 2010; 108: 65–68. 21. Taavoni S, Soltanipour F, Haghani H et al. Effects of olive oil on striae gravidarum in the second trimester of pregnancy. Complement Ther Clin Pract 2011; 17: 167–169. 22. Rangel O, Arias I, Garcia E, Lopez-Padilla S. Topical tretinoin 0.1% for pregnancy-related abdominal striae: an open-label, multicenter, prospective study. Adv Ther 2001; 18: 181–186. 23. S Kang MD. Topical tretinoin therapy for management of early striae. 1989 (August); 39(2): S90-S92. 24. Savas JA, Ledon JA, Franca K, Nouri K. Lasers and lights for the treatment of striae distensae. Med Sci. 2014 September. 29(5):1735-43. 25. Arem AJ, Kischer CW. Analysis of striae. Plast Reconstr Surg. 1980 65:22–29 26. Glassberg E, Lask GP, Tan EM, Uitto J. Cellular effects of the pulsed tunable dye laser at 577 nanometers on human endothelial cells, fibroblasts, and erythrocytes: an in vitro study. Lasers Surg Med. 1988;8(6):567–72 27. Jimenez GP, Flores F, Berman B et al (2003) Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser. Dermatol Surg 2003. (29):362–365 28. Mcdaniel DH, Ash K, Zukowski M. Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser. Dermatol Surg 1996. (22):332–337. 29. Nehal KS, Lichtenstein DA, Kamino H et al. Treatment of mature striae with the pulsed dye laser. J Cutaneous Laser Therapy 1999. (1):41–44. 30. Goldman A, Rossato F, Prati C . Stretch marks: treatment using the 1,064-nm Nd:YAG laser. Dermatol Surg. 2008. (34):686–691, discussion 691–682. 31. Yang YJ, Lee GY. Treatment of striae distensae with nonablative fractional laser versus ablative CO fractional laser: a randomized controlled trial. Ann Dermatol. 2011. (23):481–489 32. Lee SE, Kim JH, Lee SJ et al. Treatment of striae distensae using an ablative 10,600-nm carbon dioxide fractional laser: a retrospective review of 27 participants. Dermatol Surg. 2010 (36):1683–1690. 33. Gauglitz, Gerd G et al. Treatment of striae distensae using an ablative Erbium: YAG fractional laser versus a 585-nm pulsed-dye laser. Journal of cosmetic and laser therapy: official publication of the European Society for Laser Dermatology, 06/2014, 16(3):117-120. 34. Kim BJ, Lee DH, Kim MN et al (2008) Fractional photothermolysis for the treatment of striae distensae in Asian skin. Am J Clin Dermatol. 2008 (9):33–37. 35. Hernandez-Perez E, Colombo-Charrier E, Valencia-Ibiett E (2002) Intense pulsed light in the treatment of striae distensae. Dermatol Surg. 2002. (28):1124–1130. 36. Taieb EL, M Adam. Fractional CO2 laser versus intense pulsed light in treating striae distensae. Indian journal of dermatology. 2016. 61(2):174. 37. Spencer JM. Microdermabrasion. Am J Clin Dermatol 2005. (6): 89–92. 38. Karimipour DJ, Kang S, Johnson TM, et al. Microdermabrasion: molecular analysis following a single treatment. JAAD 2005. (52):215–23. 39. Mahuzier F. Microdermabrasion of stretch marks. In: Microdermabrasion or Parisian Peel in Practice, MahuzeierF., editor. Marseille, 1999. 25–65. 40. Abdel-Latif AM, Elbendary AS. Treatment of striae distensae with microdermabrasion: a clinical and molecular study. JEWDS 2008. (5):24–30. 41. Karia UK. Evaluation of various therapeutic measures in striae rubra. J Cutan and Aesthetic Surg. 2016; 9(2): 101-105 42. Nassar A, Ghomey S, EI Gohary Y, EL-Desoky F. Treatment of striae distensae with needling therapy versus microdermabrasion with sonophoresis. 2016 Oct; 18(6): 330-334. 43. Hexsel D et al. Superficial Dermabrasion Versus Topical Tretinoin on Early Striae Distensae: A Randomized, Pilot Study. 2014 May; 40 (5): 537-544. 44. Ibrahim ZA, El-Tatawy RA, El-Samongy MA, Ali DA. Comparison between the efficacy and safety of platelet-rich plasma vs. microdermabrasion in the treatment of striae distensae: clinical and histopathological study. J Cosmet Dermatol. 2015 Dec;14(4):336-46.

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45. Mazzarello V, Farace F, Ena P et al. A superficial texture analysis of 70% glycolic acid topical therapy and striae distensae. Plast Reconstr Surg 2012; 129:589e–90e. 46. Sanad EM, Aginaa HA, Sorour NE. Microneedling system alone versus microneedling system with trichloroacetic acid in the management of abdominal striae rubra: A clinical and histopathological study. J Egyptian Women’s Dermatol Soc 2015. (2):96-101. 47. Ryu HW, Kim SA, Jung HR, Ryoo YW, Lee KS, Cho JW. Clinical improvement of striae distensae in Korean patients using a combination of fractionated microneedle radiofrequency and fractional carbon dioxide laser. Dermatol Surg 2013. (39):1452–1458. 48. Comparison of Nonablative Fractional Erbium Laser 1,340 nm and Microneedling for the Treatment of Atrophic Acne Scars: A Randomized Clinical Trial. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 2016 Feb. 42 (2): 232-235. 49. Chawla S. Split face comparative study of microneedling with PRP versus microneedling with vitamin C in treating atrophic post acne scars. 7(4):209. 50. Goldman MP, Alster TS, Weiss R., A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulsed light therapy administered immediately after hyaluronic acid gel implantation Dermatol Surg. 2007; 33(5): 535-542 51. Alexiades-Armenakas M, Rosenberg D, Renton B, Dover J, et al. Blinded, randomized, quantitative grading comparison of minimally invasive, fractional radiofrequency and surgical face-lift to treat skin laxity. Arch Dermatol 2010. (146):396–405. 52. Goldman MP, Alster TS, Weiss R., A randomized trial to determine the influence of laser therapy, monopolar radiofrequency treatment, and intense pulsed light therapy administered immediately after hyaluronic acid gel implantation Dermatol Surg. 2007; 33(5): 535-542 53. Jeffrey et al. Evaluation of Safety and Patient Subjective Efficacy of Using Radiofrequency and Pulsed Magnetic Fields for the Treatment of Striae (Stretch Marks). J Clin Aesthet Dermatol. 2014 Sept; 7(9): 30-33. 54. Kim IS, Park KY, Kim BJ et al. Efficacy of intradermal radiofrequency combined with autologous platelet-rich plasma in striae distensae: a pilot study. Int J Dermatol 2012; (51): 1253–8. 55. Marx RE. Platelet-rich plasma (PRP): what is PRP and what is not PRP? Implant Dent 2001; 10: 225–8. 56. Lubkowska A, Dolegowska B, Banfi G. Growth factor content in PRP and their applicability in medicine. J Biol Regul Homeost Agents 2012; 26 (2): 3s–22s. 57. Marx RE. Platelet-rich plasma: evidence to support its use. J Oral Maxillofac Surg 2004; 62: 489–96. 58. Lee JW, Kim BJ, Kim MN et al. The efficacy of autologous platelet rich plasma combined with ablative carbon dioxide fractional resurfacing for acne scars: a simultaneous split-face trial. Dermatol Surg 2011; (37): 931–8. 59. Cervelli V, Nicoli F, Spallone D et al. Treatment of traumatic scars using fat grafts mixed with plateletrich plasma, and resurfacing of skin with the 1540 nm nonablative laser. Clin Exp Dermatol 2012; (37): 55–61. 60. Redaelli A, Romano D, Marciano A. Face and neck revitalization with platelet-rich plasma (PRP): clinical outcome in a series of 23 consecutively treated patients. J Drugs Dermatol 2010; (9): 466–72. 61. Ibrahim ZA, El-Tatawy RA, El-Samongy MA, Ali DA. Comparison between the efficacy and safety of platelet-rich plasma vs. microdermabrasion in the treatment of striae distensae: clinical and histopathological study. J Cosmet Dermatol. 2015 Dec;14(4):336-46. 62. Kim IS, Park KY, Kim BJ et al. Efficacy of intradermal radiofrequency combined with autologous platelet-rich plasma in striae distensae: a pilot study. Int J Dermatol 2012; (51): 1253–8. 63. Suh DH, Lee SJ, Lee JH et al. Treatment of striae distensae combined enhanced penetration plateletrich plasma and ultrasound after plasma fractional radiofrequency. J Cosmet Laser Ther 2012; (14): 272–6.

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Introduction to Drug-induced Photosensitivity Dr Sandeep Cliff and medical student Nikita Cliff-Patel discuss how practitioners can recognise photosensitivity and manage medication As aesthetic practitioners, we are always required to consider a patient’s medication, among other factors, prior to treatment to ensure safe and successful results. One implication that a patient’s medication may have on their skin is photosensitivity; the abnormal response or reaction to ultraviolet light, which typically presents as ‘sunburn’.1 Drug-induced photosensitivity refers to an undesirable pharmacologic reaction to light irritation following the application or ingestion of a drug to cause a phototoxic or photoallergic reaction.2 Up to 8% of reported cutaneous adverse events in clinical practice is thought to have a photosensitive element to it;3 although, it is not always recognised. Numerous drugs have been implicated in such reactions including, but not limited to: antimicrobials, nonsteroidal anti-inflammatory drugs (NSAID), cardiovascular agents and some psychotropics.1 It is well recognised by industry professionals that the under-reporting of such reactions may account for the lack of robust information and data concerning the real incidence of these reactions. Although it may not be seen frequently in an aesthetic practice, clinicians practising in this field should be familiar with the druginduced photosensitivity when taking a medical history. They should also be aware of the possible interactions that such a condition may be associated with and the potential implications.3 This article aims to introduce the reader to the concept of druginduced photosensitivity and present the ways in which to recognise and treat this should an indication arise.

A phototoxic or photoallergic reaction? Broadly speaking, drug-induced photosensitivity can be subdivided into a phototoxic or a photoallergic reaction (see Figure 1 for comparison).1,2,4 Phototoxic reactions are non-immunological, whilst

photoallergic reactions require prior immune sensitisation.5 For the vast majority of patients, if they suffer from druginduced photosensitivity, it is more common for them to present with a phototoxic reaction because often they have previously been sensitised to the drug topically on a number of occasions, whilst the application of topical agents to the skin is more commonly related to a photoallergic mechanism. For example, the topical application of psoralens – a light-sensitive drug that absorbs ultraviolet light and acts like ultraviolet radiation – can produce a phototoxic reaction.6 It must also be noted that the phototoxin (the ingredient thought to be responsible for the reaction) is not always the parent drug, but may be a metabolite of the drug.7 For example, amiodarone, chlorpromazine, and fenofibrate.8 Different patterns of phototoxic reactions may be seen to produce an immediate pricking, a burning sensation, urticarial reactions and some sunburn-like responses. The type of reaction is variable and is not always reproducible.9 Phototoxicity will occur in any individual with exposure to enough of the phototoxin ingredient and the appropriate radiation, although there must be idiosyncratic factors that render some individuals more susceptible, since not all patients taking a potential photosensitising drug get a reaction.10 We can infer that the unpredictability of such drug reactions may partly be attributable to individual differences in drug bioavailability and metabolism. Research looking at both the severity of photosensitivity and the wavelengths implicated shows huge variations with subjects exposed to the same drug. Therefore, with such individual variability, there must be other factors that influence these reactions.10

Recognising the signs Typically, radiation is absorbed by the photosensitising drug or its metabolite within the skin. The radiation can be ultraviolet B (UVB), ultraviolet A (UVA) or visible wavelengths (390-700 nm), but usually they are provoked by UVA.10 Once the energy is absorbed, photosensitising radicals are produced, leading to the phototoxic effects. Alternatively, altered chemicals change the endogenous levels of porphyrins or a lupus-like reaction can be provoked. In other words, ultraviolet lights results in changes in the biochemical environment leading to lupus-like skin reactions and similar, which may explain why some drugs such as minocycline can produce a lupus-like skin reaction in some patients.12 With a photoallergy, the altered chemical

Different patterns of phototoxic reactions may be seen to produce an immediate pricking, a burning sensation, urticarial reactions and some sunburn-like responses

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Phototoxic reaction

Photoallergic reaction

Onset of reaction

Onset is early (minutes to hours)

Onset is usually after more than five days of exposure to sunlight and to the drug and represents a type IV hypersensitivity reaction

Incidence

More common

Less common

Exposure to light

Single exposure

Multiple exposures

Mechanism

A change in the skin molecules is caused by reactive oxygen radicals, which can result in long-term damage or cell death

UV rays activate the immune system, which promotes the activation of macrophages, resulting in formation of contact dermatitis skin lesions

Location

Lesions are usually limited to areas exposed to the sunlight

The reaction extends beyond the sunlight-exposed areas

Appearance

Monomorphic appearance of severe sunburn

Polymorphic appearance, often eczematous

Reaction duration

Reaction subsides when patient avoids sunlight, with or without withdrawal of the drug

Subsides more slowly, following withdrawal of the drug

Histology

Histological lesions: erythema caused by light exposure, unicellular necrosis (sunburn cells)

Histologic lesions: similar to those of contact dermatitis with spongiosis and exocytosis with acanthosis

Table 1: General differences between phototoxic and photoallergic drug-induced photosensitivity.1,11

produces a delayed hypersensitivity response which manifests itself as an eczema-like clinical response, which can be confirmed on skin biopsy, showing the typical features of acanthosis, hyperkeratosis and spongiosis.13 As mentioned, clinical manifestations of photosensitivity include a pruritic eczematous reaction related to photoallergy, which typically develops after 24 hours or more following the initial exposure; it may be present beyond the margins of the drug contact and beyond the sun exposed areas.14 Usually, the condition resolves once the drug is discontinued, although in rare cases the reaction has been known to persist and transform into a chronic actinic dermatitis.15 In this case, referral to a specialist would be needed for confirmation and treatment, which may include long-term immunosuppressants. Phototoxicity produces an exaggerated sunburn reaction, but also lichenoid eruptions, erythema multiforme, telangiectasia and hyperpigmentation are but a few of the clinical presentations of a drug-induced phototoxic reaction. Typically, this reaction can occur within minutes to hours after sunlight exposure.16 If a skin biopsy is undertaken, it will show epidermal keratinocyte necrosis with a mixed lymphocytic and neutrophilic infiltrate; this represents an acute injury to the skin.16

Investigating symptoms Investigations that need to be undertaken when a drug is implicated involves the exclusion of other causes of the skin condition, for example an acute onset eczema or psoriasis – occurring independently of the drug – in this case a good history is paramount and usually helps the practitioner decide. The practitioner may use a lupus test, porphyrin screen and a skin biopsy. However, a thorough history will usually guide the clinician. Once the likely culprit is thought to be a drug, the key investigation is phototesting. The use of a monochromator to determine the wavelengths involved, the degree of photosensitivity, and the reaction to the suspected drug. A monochromator is a specialised tool to investigate if there is a photoallergic reaction and uses a specific wavelength to see whether a reaction can be elicited – it is provided by tertiary dermatology units in the UK. False negatives can be found, possibly implying the reaction could be due to a metabolite and not the parent drug. The investigation of choice by dermatologists when one suspects a photoallergy is photopatch testing. The patches are applied with the suspected allergen and left on for 24 hours. Two sets are applied, one is irradiated with a predetermined dose of UVA and then readings are taken by a suitably qualified individual at 48 and 72 hours; specialist interpretation is vital to avoid false positive results.17

Assessing new medication and aesthetic treatments In the case of the aesthetic practitioner, the relevance of patients complaining of drug sensitivities may become apparent with the use of sunscreens, for example, as these are frequently advocated post procedure. The majority of sunscreens that have the potential to produce a photoallergic reaction contain p-amminobenzoic acid (PABA), benzophenones, cinnamates and octocrylene.18 However, the newer sunscreens that have come to market are less associated with such reactions since they contain photostable molecules to reduce the risk of these reactions.18 Knowledge of a patient’s sensitivities will guide the clinician to use the most appropriate sunscreen. In other situations, we are frequently confronted by patients wishing to undergo laser treatment, but on direct questioning in the consultation, they declare that they are on a potentially photosensitising drug.19 The easiest option is to bar any patient from having treatment with laser whilst they are on such medication; however, this can seem unfair since it may be denying a patient treatment with a laser which does not have a wavelength associated with a known photosensitive reaction with that particular drug. The investigation can be time consuming and arduous so, for many, simply saying no is the easier option. Access to information on high risk wavelengths may go some way to reassuring both patient and clinician and with the appropriate consent and test patches, the patient may benefit.20 When using psoralen and UVA for certain skin conditions (eczema psoriasis and vitiligo) there is greater risk of provoking a phototoxic response if a patient is taking a potentially photosensitising medications. However, this will depend upon a host of factors including wavelength, the type of phototherapy, the ultraviolet dose and thus the decision to treat should be determined on an individual basis. Photosensitising drugs do not preclude phototherapy; although, it is advised that should a patient be started on a potentially photosensitising drug then phototherapy should be temporarily halted.10

Managing the signs Clearly, if drug-induced photosensitivity is suspected, then simply stopping the offending drug is all that is required. However, if there is a differential diagnosis and/or it is imperative to continue with the drug, then further investigations as delineated above is needed. In reality, it is not uncommon to be able to seek an alternative medication to treat a patient once the culprit has been determined. Rarely, when no alternative can be found, then appropriate measures need to be undertaken to protect the patient from ultraviolet exposure, in particular,

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


longer wavelengths. This may include appropriate clothing and sunscreens. For some drugs, adjusting the time of the dose and knowing the half-life may avoid the delivery of the peak concentration at the time of phototherapy exposure. This decision should be made in association with the patient’s GP. Some tertiary centres will offer patients protection by using narrowband UVB in the same way it is used for patients with polymorphic light eruption, effectively trying to desensitise them.21 In clinical practice, dermatologists frequently recommend UV therapy for a number of skin conditions. If potential medications are being taken by the patient, then assessment by trained phototherapy nurses can be undertaken and the use of lower narrowband UVB minimal erythema doses can be instigated. Although, as previously stated, UVB induced photosensitivity is less likely to be an issue than phototherapy with longer wavelengths.10

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Summary In summary, we have discussed drug-induced photosensitivity, the importance of a detailed history and to ensure that this is updated each time the patient attends. We have highlighted the clinical features and the immediate management, as well as further investigations needed to confirm the diagnosis and potential long-term management. Dr Sandeep Cliff is a consultant dermatologist and dermatological surgeon based in London and Surrey. He has lectured extensively both nationally and internationally on facial rejuvenation. Nikita Cliff-Patel is a fourth-year medical student with a passion for evidence-based medicine and its importance to clinical practice. She has completed her intercalated BSc in international health and has recently returned to clinical medicine at Leeds Medical School. REFERENCES 1. Christian Bénichou, Adverse Drug Reactions: A Practical Guide to Diagnosis and Management, 1994, Ch 44. 2. Kerstein RL, Lister T, Cole R, Laser therapy and photosensitive medication: a review of the evidence. Lasers Med Sci. 2014 Jul;29(4):1449-52. Epub 2014 Mar 4. 3. Monteiro, AN, Rato, M and Martins, C., Drug-induced photosensitivity: Photoallergic and phototoxic reactions, Clinics in Dermatology, 2016. 34:p. 517-581. 4. Frain-Bell W. Cutaneous photobiology. Oxford (UK): Oxford University Press 1985.pp.125-152 5. Ferguson J. Photosensitivtiy due to drugs. Photodermatol Photoimmunol Photomed 2002;18:262-9 6. Berakha GJ, Lefkovits G. Psoralen phototherapy and phototoxicity. Ann Plast Surg. 1985 May;14(5):458-61. 7. Kyuri Kim, Hyeonji Park, and Kyung-Min Lim, Phototoxicity: Its Mechanism and Animal Alternative Test Methods, Toxicol Res. 2015 Jun; 31(2): 97–104, 8. Masashi Kato, Gen Suzuki, et al., New Photosafety Assessment Strategy Based on the Photochemical and Pharmacokinetic Properties of Both Parent Chemicals and Metabolites, Drug Metab Dispos 43:1815–1822, November 2015 9. AF Monteiro, M Rato, C Martins, Drug induced photosensitivity: photoallergic and phototoxic reactions, Clinics in Dermatology, 2016 34,571-8 10. RS Dawe, SH Ibbotson, SH. Drug-induced photosensitivity. Clinics in Dermatology, 2014. 32: p.363-368. 11. Ewelina Bogumiła Zuba, Sandra Koronowska, et al., Drug-induced Photosensitivity, Acta Dermatovenerol Croat 2016;24(1):55-64 12. Van Steensel MA, Why minocycline can cause systemic lupus– a hypothesis and suggestions for therapeutic interventions based on it. Med Hypotheses. 2004;63(1):31-4. 13. Stein KR, Scheinfeld NS, Drug-induced photoallergic and phototoxic reactions. Expert Opin Drug Saf. 2007 Jul;6(4):431-43. 14. Brian L. Diffey & Irene E. Kochevar, Basic principles of photobiology, Photodermatology, New York: Informa Healthcare, 2007. pp.25-27 15. Baron, ED and Suggs, AK. Introduction to Photobiology. Dermatologic Clinics, 2014. 32 (3): p. 255-266. 16. Selvaag, E. Clinical drug photosensitivity. A retrospective analysis of reports to the Norwegian adverse drug reactions committee from the years 1970-1994. Photodermatol Photoimmunol Photomed, 1997. 13: p.21-23. 17. Drucker, A and Rosen, C. Drug-induced photosensitivity: culprit drugs, management and prevention. Drug Saf, 2011. 34: p.821-837. 18. Moore, DE. Drug-induced cutaneous photosensitivity: incidence, mechanism, prevention and management. Drug Saf, 2002. 25: p.345-372. 19. Collins, P and Ferguson, J. Narrow-band UV (TL-01) phototherapy: an effective preventative treatment for the photodermatoses. Br J Dermatol, 1995. 132: p.956-963. 20. Renz Mang, Helger Stege, Jean Krutmann, Mechanisms of Phototoxic and Photoallergic Reactions, Contact Dermatitis, pp 155-163. 21. Beattie, PE. Traynor, NJ. Woods, JA et al. Can a positive photopatch test be elicited by subclinical irritancy or allergy plus suberythemal UV exposure? Contact Dermatitis, 2004. 51: p.235-240.

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Aliaxin® is IBSA’s monophasic dermal filler line which easily integrates into tissue and provides natural, long lasting correction. The different molecular weights and the combination of cross-linked (FL, GP & EV) and natural HA (SR) result in both a biological effect (hydration) and mechanical action (lift) which we refer to as HYDROLIFT® Action. All products have been rheologically tailored to work in harmony for full-face treatment and 3-dimensional facial rejuvenation. The ALIAXIN® dermal filler line is one of our favourites. Especially for the outstanding product safety and high cohesivity, resulting in a good tissue integration and a natural and long-lasting effect. Patients are surprised about how much their skin has been improved. The short recovery time gives better comfort and patient compliance. The special feature of ALIAXIN SR® is defined by its effect on tissues as a result of its formulation, which includes both natural and cross-linked hyaluronic acid. following the HYDROLIFT® Action concept created by IBSA Italia. Dr Gabriel Siquier Dameto Dameto Clinics International, dametoclinics.com ALIAXIN® is IBSA’s monophasic dermal filler line, it contains a combination of well-defined molecular weights to obtain different biological & mechanical effects. Key features of the ALIAXIN® range are high tissue integration and stability resulting in natural but at the same time long-lasting results. ALIAXIN® SR is a remarkable product, there is nothing like it on the market. It is a unique combination of natural and crosslinked HA combining three molecular weights of HA for a more well-rounded blend of HYDROLIFT® Action. Dr Beatriz Molina Medikas Clinic, medikas.co.uk Before

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Patient before and six months after full face rejuvenation with the Aliaxin range


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The VISCODERM HYDROBOOSTER® is a unique skin treatment with a number of properties: it can be used as focal line corrector around the periorbital, forehead and glabellar regions, as well as mimetic and established lines around the perioral region. The syringe quantity allows the clinician to treat a number of anatomical areas in one session, whilst delivering a high level of deep hydration to the skin with high cohesivity and elastic properties – perfect for dynamic areas. The clinician has the possibility to utilise different injection planes depending on the Glogau score and/or skin quality, which is particularly useful to treat acne scarring. This can also be considered a great combination treatment with PROFHILO® to target specific areas for exceptional results in treating skin quality. Anna Baker, Aesthetic Nurse Anna Baker Aesthetics, annabakeraesthetics.co.uk

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Profhilo® is an excellent ‘skin treatment’ and I have now incorporated it within my injectable portfolio as the first step towards skin rejuvenation. The treatment training is invaluable to maximise the treatment outcome. It fits nicely into an aesthetic practice as a two-step treatment taking place 30 days apart with a follow-up. It is easy to understand – for the practitioner and also for the patient as it stimulates the dermal activity after the second treatment and my patients come back with glowing, radiant skin and an improved dermal texture. Dr Preema Vig Dr Preema London Clinic, drpreema.com

Two treatments, two months apart with Viscoderm Hydrobooster

Two treatments, one month apart with Profhilo

Aesthetics | January 2019

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this unit is greatest on the face, back and chest, hence these are the skin surfaces which are most greatly affected by acne. The density of the pilosebaceous gland remains the same during pregnancy. The pathogenesis of acne vulgaris is multifactorial. It is thought to involve many complex processes that occur within the skin that exacerbate each other, including:3 • Altered follicular keratinocyte proliferation • Androgen-induced seborrhoea • Bacterial proliferation (predominantly propionibacterium acnes) within the sebum of hair follicles • Inflammation of the pilosebaceous unit

Acne in Pregnancy Dr Jane Leonard provides an overview of the best-suited treatments to address acne vulgaris in pregnant patients Acne vulgaris is believed to affect 80% of people aged between 11-30 in the UK.1 As an inflammatory skin condition, acne can cause significant damage to the skin on a mild to severe level; ranging from skin congestion to permanent scarring. It is the one condition that I see equally in both general practice and aesthetic practice, highlighting how common the condition is and how much it affects patients on a physical, emotional and psychological level. For these reasons, I find that providing suitable solutions for patients presenting with acne to be extremely rewarding. That said, acne is still one of the most challenging conditions to treat and even more so in patients who are pregnant, appearing in one in two pregnant women.1 In my experience this is because many of those who are pregnant are unable to take many traditional methods for treating acne such as retinoids and some antibiotics.2

In addition to the causes above that effect the superficial layer of the skin, there are many other factors, both intrinsic and extrinsic, that play a role in the development of acne, such as the layer of the dermis, for example. High levels of androgens, in particular testosterone, which increases significantly when puberty kicks in, is a fundamental causative factor.3 Acne can present with lesions which can be non-inflammatory, inflammatory or a combination of both. Non-inflammatory lesions are comedones, which can be open (blackheads) or closed (whiteheads). Inflammatory lesions can present as papules or pustules. In more severe cases, inflammatory nodules can develop.4

Why is acne more common in pregnancy? Women who have not previously suffered from acne are more likely to develop the skin condition in pregnancy. This is usually due to the high levels of oestrogen in the first trimester.6 Females who already have acne when they fall pregnant are more likely to develop a more severe case of their existing problem, and this is most common during the first trimester of pregnancy, again due to the high levels of oestrogen.6 Hormone changes, such as the increased levels of sex hormones oestrogen and progesterone, are the driving force behind the development of acne in pregnancy. Progesterone is more androgenic compared to oestrogen; it acts in a similar way to testosterone by stimulating the proliferation of the sebaceous glands and increases sebum production. This process causes the frequency of acne and severity of patients’ symptoms to increase. In some cases, the increased levels of sex hormones can become semi-permanent and persist post-partum. This is due to increased bacterial proliferation in the pilosebaceous unit, which can continue after the birth of the child.7,8

Acne and its causes Acne is a chronic inflammatory skin condition that mainly affects the face, back and chest, with many patients having more than one area affected. It is characterised by the blockage and inflammation of the pilosebaceous unit of the skin, which consists of the hair follicle, its associated sebaceous gland and arrector pili muscle.2 The density of

Consulting pregnant patients The first and most important step in the consultation is to establish if the patient is pregnant and how many weeks she is. Patients may not always tell you directly that they are pregnant, as many may assume that you know already or not think it’s relevant, so try to make a point of asking this question early in the consultation and express the importance of a truthful answer.

Acne grading system Mild: The skin appears congested with predominately noninflammatory open and closed comedones. Moderate: Inflammatory lesions predominate; papules and pustules. Severe: Widespread inflammatory lesions with pustules, nodules and cysts more prominent. There may also be some evidence of scarring.5

The assessment process for pregnant women is very similar to those who are not pregnant. Firstly, you need to establish: • The duration of the acne • What areas of the body are affected • What types of lesions has the patient themselves noticed. Can you identify that there are mainly blackheads/white heads or are pustules the main problem? • Establish which treatments the patient may have previously tried

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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already (both before and during pregnancy) and the response achieved. This is to ensure no teratogenic medications have been or are being taken by the patient • Possible exacerbating factors The main exacerbating factor in this context is pregnancy and it is important for practitioners to confirm the stage of pregnancy that the acne first started. Practitioners should also consider: • If the patient suffered with acne before they became pregnant • If they have a family history of acne • If they have a history of other hormonal problems that can also predispose them to developing acne, such as polycystic ovary syndrome • If they have changed their diet The latter is particularly relevant in pregnancy as a woman’s diet may vary due to changes in food cravings and associated pregnancyrelated conditions such as hyperemesis. This may mean women are excluding particular food groups from their diet or having a more restricted diet, as only certain foods can be tolerated. This is particularly common in the first trimester of pregnancy when oestrogen levels spore, potentially resulting in nausea and vomiting.9 Psychological effects Sadly, the psychological effects of acne are often underestimated and misdiagnosed in many cases. The impact that acne has on selfconfidence and self-esteem can be just as severe as the physical effects of acne on the skin.10 In my opinion, it is vital that aesthetic practitioners are empathetic towards patients who are suffering with acne and encourage them to be open with how the condition is making them feel. This is especially important in pregnancy as the hormonal changes that cause the initial flare-up in acne can also affect the patient’s mood.

Treatment As extra care needs to be taken when treating women who are pregnant, there are many challenges that practitioners must be aware of to manage these patients appropriately. I find that the most prominent challenges of treating acne in pregnancy are: • The increased potency of intrinsic hormonal causative factors (discussed above) • Treatments are limited as many drug and aesthetic treatments are teratogenic • There is limited data available related to the safety of many aesthetic treatments for pregnant patients Treatment plans As the medical and aesthetic treatment opinions are greatly limited during pregnancy, it is important to be open with patients about this prior to constructing a treatment plan for them. During this discussion, it is a good opportunity to identify the patient’s expectations so that you can manage these appropriately. Firstly, there are many simple things patients can do safely during pregnancy that can optimise their health and skin quality both during and after pregnancy. They mainly depend on the type of acne that the patient is experiencing, whether it be mild, moderate or severe.

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Some patients may want to try as many treatment approaches as possible, as their appearance and psychological impact of acne may greatly affect them. Other women may only entertain more natural treatments and prefer to doing nothing until the baby is born. If she prefers to do less, always leave the door open for her to return in future, without pressure. Acne has such an emotional effect; especially during pregnancy. I believe it is vital we respect our patients’ decisions and support them at all times. For all patients, practitioners should advise that they avoid picking and squeezing their spots as this can spread bacteria, exacerbate inflammation and can cause scarring. They should also advise patients to use gentle skincare products that contain mostly natural ingredients, as over cleansing the skin can trigger an excess production of sebum to compensate for this.11 In addition, patients should use oil-free makeup and avoid products that are heavy on the skin surface, as oil-based products and emollients contain heavy molecules that cannot penetrate into the skin, for example products containing mineral oils and silicones, as these are comedogenic. They should also ensure their skin is adequately hydrated and that they consume a healthy, balanced diet. Low risk treatments As mentioned, the main limitation of aesthetic treatments when treating acne in pregnant patients is the lack of evidence in terms of safety. Many practitioners and aesthetic clinics tend to opt to avoid treating pregnant patients to be on the side of caution. The best interests of the mother and unborn child must always come first. Many agree that topical treatments are the safest way to treat pregnant patients who are experiencing some form of acne. However, it is important to note that not all ingredients are deemed as low risk. Ingredients such as benzoyl peroxide, azelaic acid, glycolic acid and low concentration salicylic acid (patient dependent) are the only ones deemed as low risk and are suitable so I would incorporate into a treatment.18 Oral antibiotics that are safe to prescribe in moderate and severe cases include penicillin, erythromycin and cephalosporins.12 It is important to note, that prescribing prolonged courses of antibiotics can cause vaginal thrush, which is extremely common in pregnant patients.13 Treatments to avoid Due to the lack of data, the safety of using aesthetic treatments, such as laser therapy, radiofrequency and chemical peels to address acne in pregnancy is uncertain. I would therefore recommend that these types of treatments are avoided.14-16 Treatments to avoid at all costs are topical retinoids such as tretinoin, topical isotretinoin and adapalene, as well as high concentrations of salicylic acid (patient dependent) – these are teratogenic and should therefore never be used.17

The impact that acne has on self-confidence and self-esteem can be just as severe as the physical effects

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Oral antibiotics to avoid include: • Tetracyclines, such as doxycycline, minocycline and lymecycline – especially in the third trimester • Trimethoprim • Sulfamethoxazole • Fluoroquinolones18 The treatment which poses the highest risk for pregnant patients suffering from acne is oral isotretinoin. This should never be used to treat women who are pregnant, as it can potentially disturb the development of the embryo or foetus. Isotretinoin can be an effective treatment for severe acne, as it is a derivative of vitamin A and part of the retinol family.12

Conclusion Practitioners must take extra care when treating patients who are pregnant. Due to the lack of data surrounding the safety of many treatment approaches for acne, I always say that it is better to be safe than sorry. Therefore, I would always avoid the use of laser therapy, radiofrequency, chemical peels, certain skincare ingredients and oral antibiotics and never prescribe isotretinoin. Dr Jane Leonard is a GP and cosmetic doctor. She specialises in skin conditions, antiageing medicine and bioidentical hormones. Dr Leonard achieved a first-class honours degree in Anatomical Sciences, specialising in head and neck. She has also spent time in dermatology research and has had her worked published in Australia.

REFERENCES 1. British Skin Foundation. New survey aims to reveal if acne is part of growing up or a cause of silent misery for millions. 2012. <http://www.britishskinfoundation.org.uk/LinkClick. aspx?fileticket=DAHfKofYgBg%3D&tabid=172> 2. Ravenscroft J, Evidence based update on the management of acne, British Medical Journals, 2005 <https://ep.bmj.com/content/90/4/ep98> 3. National Institute for Health and Care Excellence, Acne Vulgaris, 2018 <https://cks.nice.org.uk/ acne-vulgaris> 4. DermNet NZ, Comedonal acne, 2014 <https://www.dermnetnz.org/topics/comedonal-acne/> 5. Sarah Purdy, Acne Vulgaris, BMJ Clin Evid, 2008; 2008: 1714. 6. Edede T, Arch E, Berson D, Hormonal Treatment of Acne. In Women, Journal of clinical and aesthetic dermatology, 2009 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923944/> 7. BMJ, Skin disease in pregnancy <https://www.bmj.com/content/348/bmj.g3489> 8. BMJ, Sepsis in adults <https://bestpractice.bmj.com/topics/en-gb/101> 9. Lee N, Saha S, Nausea and vomiting of pregnancy, Gastroenterology Clinics of North America, 2013 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3676933/> 10. American Academy of Dermatology, Acne can put a damper on hopes of glowing skin during pregnancy, 2014 <https://www.aad.org/media/news-releases/acne-can-put-a-damper-on-hopes-ofglowing-skin-during-pregnancy> 11. DermNet NZ, Seborrhoea, 2014 <https://www.dermnetnz.org/topics/seborrhoea/> 12. NICE, Browse Drugs, 2018. <https://bnf.nice.org.uk> 13. Young G, Jewell D, Topical treatment for vaginal candidiasis (thrush) in pregnancy, 1999. <https:// www.cochrane.org/CD000225/PREG_topical-treatment-for-vaginal-candidiasis-thrush-inpregnancy> 14. Panchaud A, Csajka C, Merlob P et al. Pregnancy outcome following exposure to topical retinoids: a multicentre prospective study, Journal of Clinical Pharmacology <https://www.ncbi.nlm.nih.gov/ pubmed/22174426> 15. Browne H, Mason G, Tang T, Retinoids and pregnancy: an update, The Obstetrician & Gynacologist, 2013 <https://obgyn.onlinelibrary.wiley.com/doi/pdf/10.1111/tog.12075> 16. European Medicines Agency, Updated measures for pregnancy prevention during retinoid use, 2018 <https://www.ema.europa.eu/documents/press-release/updated-measures-pregnancyprevention-during-retinoid-use_en.pdf> 17. Cross R, Ling C et al, Revisiting doxycycline in pregnancy and early childhood, Expert Opinion on Drug Safety, 2016 <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4898140/> 18. Pina Bozzo, Angela Chua-Gocheco, & Adrienne Einarson, Safety of skin care products during pregnancy, Can Fam Physician. 2011 Jun; 57(6): 665–667. 19. Malvasi A, Tinelli A, Buia A, De Luca GF, ‘Possible long-term teratogenic effect of isotretinoin in pregnancy,’ Eur Rev Med Pharmacol Sci. 2009 Sep-Oct;13(5):393-6 <https://www.ncbi.nlm.nih.gov/ pubmed/19961047>

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Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


3

COMMENDED 2018

4


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Treating the Cupid’s Bow Mr Jeff Downie and Mr Mark Devlin present an introduction for treating the upper lip and explore how to achieve safe, successful results As aesthetic practitioners, we are all well-aware that lip augmentation is among the most popular patient request when it comes to dermal fillers. All the various facial features play a part in an individual’s attractiveness, but having full, defined lips helps provide the perception of youthfulness.1 A recognised lip trend that is commonly covered by consumer press is a well-defined Cupid’s bow.2,3,4 This refers to the double curve of the upper lip vermilion that is said to resemble the bow of the Roman God of Love, Cupid.5 Some are lucky enough to have a beautifully defined upper lip; but, for those less fortunate, it is an aesthetic ideal that many aspire to. With a thorough consultation, excellent anatomy knowledge and careful injection technique of dermal filler, a more defined Cupid’s bow can be achieved.

Pre-treatment considerations As with all medical aesthetic treatments, practitioners should perform a full clinical assessment, which includes taking a medical history and educating the patient of the treatment plan and product. A full explanation of possible complications should be given and consent achieved in the form of a signature. They should also highlight to the patient that facial attractiveness varies for individuals and emphasise that treatment is not a ‘one size fits all’ approach. This is especially important for practitioners to recognise, as we are continuously seeing lip augmentation results on social media and in the press that do not complement the patient’s unique facial features and sit well outside the norm. In the consultation, give patients all the various treatment options, along with the benefits and downsides of these, which is likely to

include surgery, dermal fillers, semi-permanent tattooing, as well as recommending no treatment. There are several circumstances where treatment is contraindicated; we would be wary if there has been a recent cold sore, and certainly wouldn’t treat if there was an active cold sore on the lip. A history of allergy to objective products may also be an area of caution, and a patient with unrealistic expectations or with a request to make an alteration to their appearance that made no sense would also be a big red flag. It’s important to identify the patient’s expectations and determine what is achievable before treatment. You also need to recognise and document any discrepancies to the entire lip and surrounding areas, such as inner or outer scars, trauma, lumps, bumps, mucous cysts or any asymmetries. Often patients don’t notice existing deformities, so it’s important to make patients aware of these and record them so they don’t later blame your treatment as the cause. Another thing to note when treating the Cupid’s bow is that we would usually never recommend treatment in isolation. Treatment usually involves the use of fillers in both the upper and lower lip, with an emphasis on definition in the top, so be sure to highlight this to the patient. This is unless there is a pre-existing abnormality, such as a unilateral cleft-lip and palette, a scar, a lack of volume due to trauma or obvious asymmetry. Take very thorough, robust documentation that includes before and after clinical photographs. These come in useful, particularly when managing any disappointment or complaints that may arise. Ensure you enforce a cooling-off period so the patient can reflect upon your proposed treatment plan, as per guidance from the General Medical Council.6

Anatomy The major complication that can arise following filler placement, which most practitioners worry about, is either a vascular occlusion or an intravascular injection.7,8 If you understand the anatomy and where the vessels lie, then the risk of vascular events are significantly minimised. You are also more likely to get better results and a more satisfied patient. In the upper lip, the superior labial artery lies deep to the muscle, just below the mucosa on the inner aspect of the lip. There will normally be two branches of the columellar artery, which run almost parallel and lie in the middle of the lip. They run up to the nose and these vessels are also lying deep to the muscle (Figure 1 & 2).9 Many note the importance of lip ratios when assessing and treating

Philtral Groove Alar rim Philtral Columns Vermillion Border

Nasal Sill

Cupid’s bow Oral commisure Tubercle

Mentolabial furrow

Figure 1: Anatomy of soft tissue in perioral area9

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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If you inject too much volume into the lip, the Cupid’s bow could become flattened, and this can cause a problem with definition

the lip. For example, it is commonly quoted in the literature that to achieve the aesthetic ideal, the lip proportions should be one third top lip, two thirds bottom lip for Caucasians (1:2 or 40% upper and 60% lower lip volume) and equal ratios for those of ethnic descent (1:1 or 50% upper and 50% lower lip volume).10 However, today’s practitioners need to consider the fact that these ideals do change with trends. For example, the balance between the top and bottom lip in terms of the aesthetic ideal has been altered and more recent evidence suggests that the ideal has now become 1:1, with the upper lip having much more volume than previously recommended.11 Of course, as stated we believe it’s more appropriate to treat every individual lip in a bespoke way and assess how it appears on a unique face, rather than strive for these ratios exactly. A full understanding how the underlining hard tissue, skeletal support and dentition affects the appearance of the face will also impact treatment outcome.12 Always assess and understand these supportive structures in relation to lip support. Some patients, even relatively young patients, may have a denture, which can impact the appearance of the lip and therefore your treatment. Knowledge of gum and teeth health is also of importance; we recommend that practitioners seek training in examining the oral cavity. By using a good light and a trained eye, practitioners should

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inspect the lip by everting it to look inside. Then they can check the dental and gum health and look for concerns such as lumps, periodontal disease or dental caries. If disease is noticed, for example a dental abscess, you should avoid filler treatment and refer to a dental practitioner to address this issue first.

Treatment When it comes to the Cupid’s bow, practitioners must determine whether you need to redefine a lip that once had a nice distinct bow or if you need to create one that never existed in the first place. As patients age, they lose volume in the lip, which may result in a reduction in the definition of the upper lip and a once wellshaped Cupid’s bow can become flattened.13 For these patients, treatment can be very straightforward and all that is needed is to restore volume for an immediate recreation of what was once there. You can create volume by injecting filler just within the vermillion of the lip below the skin vermillion border. If you stay superficial to muscle then that will rotate the Cupid’s bow upwards and you will get a nice natural rotation of the lip, which will improve the profile. Then you can just continue to volumise as needed to restore what previously existed. Be careful not to over-volumise. If you inject too much volume into the lip, the Cupid’s bow could become flattened, and this can cause a problem with definition. Many younger adults have this over-volumised, undefined upper lip shape and it looks unnatural and over-inflated. Similarly, if you overinflate the vermillion border it will result in a ski jump effect and produce the classic ‘duck lips’, which most want to avoid. For patients who have never had a defined Cupid’s bow, the approach is a bit trickier. This treatment can have varying results, and it may require several treatment sessions before you achieve the most ideal result. Our method would be to inject on the vermillion itself, below the mid portion of the lip. What you might want to create is a tubercle, a volumised effect in the central portion of the lip that lies underneath the philtral groove. If you create volume in here, and consider putting very small amounts of filler in the philtral ridges themselves, that should lift the Cupid’s bow up. Our recommended amounts are usually around 0.1-0.2ml to each area at one time. It’s important that you do this treatment in small incremental steps to build the Cupid’s bow and the philtral columns. We also advise that practitioners allow the patient to sit with a mirror in their hand and seek their input and feedback after injecting the tiny amounts of product, to determine if they are appreciating the changes.

Levator labii superioris

Zygomaticus minor

Columellar artery

Zygomaticus major

Superior labial artery

Risorius

Inferior labial artery

Orbicularis oris

Mental artery Labiomental artery

Depressor anguli oris Depressor labii inferioris

Submental artery (terminal part)

Figure 2: Where the vessels lie in relation to the muscle9

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Needles vs. cannulas When treating the Cupid’s bow we prefer needles as we believe there is a greater degree of control and you can achieve more precise product placement. However, we always advise those new to aesthetics that using a cannula is safer to prevent damaging the blood supply. As mentioned, the blood supply is deep to the muscle, and if you use a cannula and stay superficial to the muscle, then it can be a safer treatment. If you are a confident, experienced practitioner then a needle can be a very precise way of treating lips, but practitioners may use both depending on what they want to achieve. For example, volumisation of the body of the lip with a cannula using a linear threading technique and definition of the Cupid’s bow with accurate small volume injections using the needle.

We always advise those newer to aesthetics that using a cannula is safer to prevent damaging the blood supply Product selection If injecting superficially, we would recommend a product with a low G’ prime, so it blends into the vermillion border or philtral column. If you are injecting deep, then we recommend a product with a higher G’ prime, which will help to provide more volume. We prefer to use products from the Restylane portfolio (Restylane Kysse when treating lips), but many other hyaluronic acid products will give suitable results. As we use fillers that contain intrinsic Lidocaine, patients can tolerate lip injections very well without any anaesthetic, so our personal preference is to use either topical anaesthetic or nothing at all.

to create a defined Cupid’s bow on a patient who never presented with one to begin with. Treat these patients with care and suggest injecting product over several sessions to build results over time. Mr Jeff Downie is a consultant oral and maxillofacial surgeon who has a specialist interest in facial aesthetic and reconstructive surgery. He practises facial surgery in Glasgow and his NHS sub-speciality is facial deformity and post-traumatic facial reconstruction. In addition, he treats skin cancers, salivary gland disease and is trained in all aspects of hard and soft tissue oral-facial surgery. Mr Mark Devlin works as one of three cleft lip and palate surgeons in Scotland and is also a consultant maxillofacial surgeon. He is based at both the Royal Hospital for Sick Children and the Southern General Hospital in Glasgow. His clinical training has been comprehensive in the management of facial disfigurement and aesthetic dissatisfaction. He works as part of a team within BMI Ross Hall Hospital that endeavours to provide a safe, comprehensive and high quality service to patients. REFERENCES 1. Etcoff N. Survival of the Prettiest: The Science of Beauty. New York: Doubleday; 1999. 2. Google Trends, ‘Cupid’s Bow’, November 2018. <https://trends.google.com/trends/ explore?date=all&q=Cupid%27s%20bow> 3. Female First, 10 Things You Need To Know About The New Cupid’s Bow Lip Trend, May 2018. <https://www.femalefirst.co.uk/lifestyle-fashion/10-things-you-need-to-know-about-the-cupids-bowlip-treatment-1145040.html> 4. Stephanie Buck, Your upper lip has never been more important: The crucial cupid’s bow, Timeline, September 2016. 5. Dictionary.com, Cupid’s Bow. <https://www.dictionary.com/browse/cupid-s-bow> 6. GMC, Guidance for doctors who offer cosmetic interventions, April 2016. 7. Funt D, Pavicic T, Dermal fillers in aesthetics: an overview of adverse events and treatment approaches, Clin Cosmet Investig Dermatol, 2013, 6:295–316. 8. DeLorenzi C, Complications of injectable fillers, part 2: vascular complications, Aesthet Surg J, 2014 May 1;34(4):584-600. 9. Cotofana S et al., Distribution Pattern or the Superior and Inferior Labial arteries, Plast Reconstr Surg. 2017. 10. Popenko NA, Tripathi PB, et al., A Quantitative Approach to Determining the Ideal Female Lip Aesthetic and Its Effect on Facial Attractiveness, JAMA Facial Plast Surg, 2017 Jul 1;19(4):261-267. 11. Paul I. Heidekrüger, Sabrina Juran, et al., ‘The Current Preferred Female Lip Ratio’, Journal of Cranio-Maxillofacial Surgery, 2017. 12. Padmaja Sharma, Ankit Arora, and Ashima Valiathan, Age Changes of Jaws and Soft Tissue Profile, The Scientific World Journal, Volume 2014, article ID 301501. 13. Uwe Wollina, Perioral rejuvenation: restoration of attractiveness in aging females by minimally invasive procedures. Clin Interv Aging. 2013; 8: 1149–1155. 14. Aesthetics Complications Expert (ACE) Group stats 2016-2018. Data on file.

WA NT TO L E A RN M ORE?

Complications Latest stats from the Aesthetics Complications Expert (ACE) Group indicate that 53% of the total number of filler-related complications that were reported between 2016-2018 were associated with lip augmentation.14 Although it is actually quite rare to get a serious complication in relation to blood supply of the face, it is not uncommon to get complications such as light bruising and swelling for example, and thorough knowledge of the anatomy will prevent more serious events. Ultimately, we find that the biggest complaint or concern from aesthetic treatments is the patients not being happy with the results. If you have agreed upon the treatment plan, have been transparent about the results you can achieve and you are careful about how you do it, that’s when you will achieve good, uncomplicated results that the patient should be pleased with.

Summary A defined Cupid’s bow is an aesthetic ideal for many patients. If the patient previously had definition which has reduced due to ageing, rejuvenating the area with volumising fillers can recreate what was once there. Although still achievable, a more complex procedure is

Join Mr Jeff Downie and Mr Mark Devlin for their webinar on January 25 at 10am-12pm, where they will discuss the anatomy of the smile. The webinar will be hosted on the Aesthetics journal website and will also feature a lip injection demonstration by aesthetic nurse practitioner Jackie Partridge and a talk on how to build your business with the smile by Professor Bob Khanna.

The webinar is sponsored by Galderma For more information, go to www.aestheticsjournal.com/news/galderma-webinar-details

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Benign essential blepharospasm Benign essential blepharospasm (BEB) is characterised by progressive bilateral involuntary spasms of the eyelid protractors (orbicularis oculi, corrugator, and procerus).5 It is a form of focal dystonia, which is defined as an involuntary prolonged contraction affecting a single body part or group of muscles. It has a prevalence of 5 to 13 per 100,000 people and is three times more common in females than males.3 BEB often involves the mid-face elevators and mouth or tongue. Neck involvement is also observed in severe cases.5 Presentation ranges from a mildly increased blink rate to forceful eyelid closure, which results in functional blindness.6 Photophobia, sensitivity or discomfort to light exposure occurs in approximately 80% of patients and often triggers eyelid spasms.4 Symptoms are also worse when patients are immersed in a moving visual field, for example while a passenger in a car. Symptoms may improve with concentration, physical tasks, talking, and are often ameliorated by downward gaze, shutting one eye or by applying focal pressure on the temple.5 BEB is a chronic and incurable condition. It typically progresses rapidly before becoming stable; remission is rare. It can be a disabling condition and may result in a limitation of activities as a part of daily living and reduced quality of life.7 Chronic BEB may lead to Consultant oculoplastic surgeon Mr Daniel permanent anatomical sequelae, such as blepharoptosis, Ezra and Dr Michelle Ting look at some of the due to dehiscence of levator palpebrae superioris or entropion, because of the stretching of the lateral most common dystonias in the periocular canthal tendon. Patients often overuse their frontalis area and advise on suitable treatment to help ‘break’ spasmodic episodes, which may result in stretching and brow ptosis.8 The aetiology of BEB Involuntary eyelid twitching is a common presenting symptom to is thought to be multifactorial. The majority of cases are sporadic; ophthalmologists. The differential diagnosis of periocular dystonias however, approximately 20% have a positive family history of include eyelid myokymia, benign essential blepharospasm and dystonia, suggesting a possible genetic aetiology.9 BEB may be a hemifacial spasm. Each of these has a different cause, management feature of other movement disorders such as Parkinson’s disease and prognosis. In such patients, it is important to establish the correct or Parkinsonian-plus syndromes, or tardive dystonia following diagnosis, rule out underlying pathology and provide a holistic neuroleptic treatment (commonly administered for psychiatric approach to treatment. This range of conditions is of particular interest conditions). In keeping with this, neuropathological studies in BEB to aesthetic professionals who are likely to encounter such concerns have shown abnormalities in the basal ganglia.10,11 as they treat the eye area with filler or botulinum toxin. It is important to The ocular surface disease plays an important role in the note, however, that anyone performing these treatments must have the pathophysiology of BEB. In one study of 272 patients with correct training and suitable knowledge of the anatomy and underlying blepharospasm, 57% had symptoms of ocular surface disease such disease. If they do not, I would recommend referring to a specialist. as dryness, grittiness or irritation.12 It has been suggested that the increased blink rate initiated by dry eye becomes perpetuated and Differential Diagnosis inappropriate as a result of induced trigeminal hypersensitivity.13 In my experience, BEB is frequently misdiagnosed as dry eye syndrome, Eyelid myokymia resulting in delayed diagnosis. Eyelid myokymia presents as gentle twitching of one eyelid, often described as a ‘fluttering’. It usually affects the lower lid, and typically occurs unilaterally. The movement is due to fasciculation of orbicularis oculi fibres.1 When both eyelids are involved, they twitch independently of each other. Contractions are self-limiting and episodic, lasting for a few seconds, but runs of these fasciculations can last for weeks or months. Myokymia can present at any age, although it is most frequently seen in adults. It is associated with fatigue, anxiety, stress, exercise and excessive use of caffeine.1 It is a benign condition, which tends not to be associated with other neurologic disease. The majority of cases resolve spontaneously; chronic cases respond well to treatment with botulinum toxin.2

Understanding Periocular Dystonias

Examination should involve an assessment of muscles affected, blink rate, and the presence of forced and prolonged eyelid closure

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Hemifacial spasm Hemifacial spasm (HFS) is characterised by a unilateral involuntary, irregular, tonic contraction of the muscles innervated by the facial nerve. It can involve small parts of the face, or can be much more extensive, affecting the entire side of the face, including the platysmal neck muscles and brow.14 HFS usually presents between 40 and 50 years of age, with an average prevalence of 7.4 per 100,000 in men and 14.5 per 100,000 in women.14 Orbicularis oculi is the most common initial site before spreading to the lower face over months to years.14 In contrast to BEB, most cases of HFS are unilateral and the spasms may occur during sleep. The spasms may be associated with ipsilateral pain and are often exacerbated by coughing, fatigue or stress. HFS is usually caused by the compression of the facial nerve root exit zone by an aberrant loop of the anterior inferior cerebellar, posterior inferior cerebellar, vertebral, or basilar artery.15 Other rarer causes of HFS include meningioma, schwannoma, parotid gland tumour, and pilocytic astrocytoma, causing facial nerve compression.16 All patients with HFS should be investigated with an MRI brain scan focusing on the facial nerve pathway to exclude a space-occupying lesion.

Evaluating patients with periocular dystonia Clinical evaluation should include a thorough medical, drug and family history. Examination should involve an assessment of muscles affected, blink rate, and the presence of forced and prolonged eyelid closure. Assessing the muscle groups involved requires careful observation of the spasm and a detailed understanding of the function of the periocular musculature. It is also important to assess for occlusion positivity (improvement of symptoms with occlusion of either eye) and for relieving pressure points, which are typical in blepharospasm. Based on experience, I believe a complete cranial nerve exam should be performed, including testing of corneal sensation. A peripheral neurological exam must also be carried out to identify signs of Parkinsonism. An ophthalmic examination with slit-lamp biomicroscopy is also essential to identify blepharitis and dry eye.5 These examinations are usually carried out by doctors specialising in neurology or ophthalmology so would need to be referred on. When dealing with BEB or HFS, which are more severe than myokymia, the effect of the condition on the patientâ&#x20AC;&#x2122;s quality of life can be objectively assessed using various quality of life scales. The Blepharospasm Disability Scale (BDS) is an effective measure that can be completed quickly with minimal instruction.17

Treatment Each condition has a different treatment approach, but will usually involve the administration of botulinum neurotoxin (BoNT). Myokymia rarely requires treatment, but if bothersome, low-dose toxin injections (approximately 0.5-1 units/0.1ml for Botox and Xeomin, or 10-20 units/0.1ml for Dysport, for example) can be given directly to the affected areas with symmetrising doses to the contralateral side. HFS Patients with HFS also respond well to treatment with BoNT injections.18 Injections need to be administered carefully to control the affected muscles, with great care taken to ensure that the ipsilateral antagonist muscles and contralateral corresponding muscles are also treated where necessary to maintain facial symmetry. The location and dosing of these injections is completely bespoke for each patient.

This range of conditions is of particular interest to aesthetic professionals who are likely to encounter such concerns as they treat the eye area with filler or botulinum toxin The most common muscle groups injected are frontalis, orbicularis oculi, corrugators, zygomaticus major, medial mid-face and lip elevators (levator labii superioris at alaeque nasi, platysma and depressor anguli oris). The clinical decision for treatment is based on very careful observation of affected muscle groups, as well as patient expectations. Sometimes neurosurgical referral for microvascular decompression of the facial nerve can be considered, and this is curative in up to 90% of cases.19 BEB When managing patients with BEB, more of a holistic approach is required. Patient education and supportive care are fundamental. Support groups such as the Benign Essential Blepharospasm Research Foundation (BEBRF) and the Dystonia Society in the United Kingdom can be recommended to give patients support.29,30 In one study of 1,653 patients, 90% of patients felt that the support groups had provided them with considerable assistance.4 Ophthalmic management of the afferent blink reflex pathway is also vital. Treatment of dry eye should be addressed with the use of lubricants (for example hypromellose, carmellose or sodium hyaluronate eye drops) and treatment of blepharitis with hot compresses or short-term topical steroids.32 Patients with BEB tolerate a lower intensity of light than normal subjects. Some patients may benefit from wearing lenses such as FL-41 tints (glasses with therapeutic tinted lenses) or from the use of Bangerter occlusion foils (translucent plastic filters which block light transmission that reduce visual activity).20 However, the mainstay of treatment of BEB is BoNT. The American Academy of Ophthalmology collected data on 4,340 patients with blepharospasm treated with BoNT, and found that 90% clinically improved.21 BoNT is injected subcutaneously into four to five sites around the orbicularis oculi muscle. Adverse effects include bruising, ptosis, dry eye, entropion (in-turning of the lower lid), ectropion (outturning of the lower lid), and excessive tearing. These are usually short-lived in relation to the period of therapeutic benefit.22 To prevent ptosis, one should avoid injecting around the central preseptal part of the upper orbicularis oculi. Numerous studies have shown the benefit of injecting BoNT into the pretarsal rather than the preseptal portion of the orbicularis.29-31 Pretarsal injections appear to improve response when pretarsal

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spasm is present, although they tend to be more painful and have a higher incidence of bruising.23 Other muscles such as the procerus, corrugators and mid-face elevators are also often injected. Planning BoNT therapy in BEB is highly complex and requires a detailed assessment of the affected muscles. It is given in low to standard doses (for example, 1.25-5 of Xeomin or Botox and 5-20 units of Dysport per injection site) with early review of its effects. Initial effect is generally seen within three days and reaches a peak one to two weeks’ post treatment. The optimal dose is the least amount of BoNT necessary to achieve the desired outcome without adverse effects. The duration of the BoNT treatment is approximately three months for all of these conditions, after which repeat injections may be given if required. Intervals between injections of less than nine weeks and booster injections two weeks after the initial injection should be avoided as they may predispose to biological resistance.24 Long-term loss of effectiveness of the treatment is rare, and is thought to be due to the formation of neutralising antibodies.25 Systemic treatment Systemic treatments are an important treatment modality when patients with BEB are unresponsive to BoNT injections. Improvements have been demonstrated in small numbers of patients taking a range of drugs, including haloperidol, l-dopa and deprenyl, trihexyphenidyl, and clonazepam. However, there appears to be no consistent or predictably effective systemic drug treatment available.26 Surgical treatment Surgery can be of benefit in patients with BEB who are refractory to medical therapies. Constant and forced closure of the eyes can cause brow descent and excess upper lid skin. The mechanical compaction can be relieved with surgical correction such as brow lifting, blepharoplasty or ptosis repair, which can be extremely effective. In addition, the frontalis sling operation is highly effective in patients with apraxia of eyelid opening.27 It is important to warn patients that surgery is not usually curative and continued treatment with BoNT injections is necessary alongside this.

Conclusion Although eyelid twitching may seem an innocuous symptom, it represents a variety of possible conditions, each with different aetiopathologies and treatments. Unresolved periocular spasms should always be referred to a specialist for evaluation. The diagnosis of myokymia, blepharospasm and hemifacial spasm can be easily confused. In some patients, ongoing symptoms may represent serious underlying pathology, which will require specialist multidisciplinary management. Therefore, if symptoms persist then referral to an ophthalmologist or neurologist is essential. Mr Daniel Ezra is a consultant oculoplastic surgeon at Moorfields Eye Hospital and honorary associate professor at the UCL Institute of Ophthalmology in Central London. He is also the head of department and service director of Oculoplastic Surgery. Mr Ezra has published widely on eyelid movement disorders and runs a busy private practice based on Harley Street and at Moorfields.

REFERENCES 1. Kennard C, Leigh R. J, Neuro-Ophthalmology, Handbook of Clinical Neurology, 3rd ser., v. 102 (Edinburgh ; New York: Elsevier, 2011). 2. Banik R, Miller N, ‘Chronic Myokymia Limited to the Eyelid Is a Benign Condition’, Journal of NeuroOphthalmology: The Official Journal of the North American Neuro-Ophthalmology Society, 24.4 (2004), 290–92. 3. Defazio G, Livrea P, ‘Epidemiology of Primary Blepharospasm’, Movement Disorders: Official Journal of the Movement Disorder Society, 17.1 (2002), 7–12. 4. Ross A H et al. ‘Review and Update of Involuntary Facial Movement Disorders Presenting in the Ophthalmological Setting’, Survey of Ophthalmology, 56.1 (2011), 54–67 <https://doi.org/10.1016/j. survophthal.2010.03.008>. 5. Lee JM, Baek JS, Choi HS, Kim SJ, Jang JW, Korean Journal of Ophthalmology, Clinical features of benign essential blepharospasm in Korean Patients, October 2018 6. Hall T A et al. ‘Health-Related Quality of Life and Psychosocial Characteristics of Patients with Benign Essential Blepharospasm’, Archives of Ophthalmology (Chicago, Ill.: 1960), 124.1 (2006), 116–19 <https:// doi.org/10.1001/archopht.124.1.116>. 7. Gillum W. N, Anderson R. L, ‘Blepharospasm Surgery. An Anatomical Approach’, Archives of Ophthalmology (Chicago, Ill.: 1960), 99.6 (1981), 1056–62. 8. Stojanović M, Cvetković D, Kostić V S, ‘A Genetic Study of Idiopathic Focal Dystonias’, Journal of Neurology, 242.8 (1995), 508–11. 9. Kulisevsky J et al. ‘Meige Syndrome: Neuropathology of a Case’, Movement Disorders: Official Journal of the Movement Disorder Society, 3.2 (1988), 170–75 <https://doi.org/10.1002/mds.870030209>. 10. Mark M H et al. ‘Meige Syndrome in the Spectrum of Lewy Body Disease’, Neurology, 44.8 (1994), 1432–36. 11. Elston J S et al. ‘The Significance of Ophthalmological Symptoms in Idiopathic Blepharospasm’, Eye (London, England), 2 ( Pt 4) (1988), 435–39 <https://doi.org/10.1038/eye.1988.79>. 12. Evinger C et al. ‘Dry Eye, Blinking, and Blepharospasm’, Movement Disorders: Official Journal of the Movement Disorder Society, 17 Suppl 2 (2002), S75–78. 13. Wang A, Jankovic J, ‘Hemifacial Spasm: Clinical Findings and Treatment’, Muscle & Nerve, 21.12 (1998), 1740–47. 14. Girard n et al. ‘Three-Dimensional MRI of Hemifacial Spasm with Surgical Correlation’, Neuroradiology, 39.1 (1997), 46–51. 15. In-Bo Han et al. ‘Unusual Causes and Presentations of Hemifacial Spasm’, Neurosurgery, 65.1 (2009), 130–37; discussion 137 <https://doi.org/10.1227/01.NEU.0000348548.62440.42>. 16. Lindeboom R et al. ‘The Blepharospasm Disability Scale: An Instrument for the Assessment of Functional Health in Blepharospasm’, Movement Disorders: Official Journal of the Movement Disorder Society, 10.4 (1995), 444–49 <https://doi.org/10.1002/mds.870100407>. 17. Yoshimura D M, Aminoff M J, Tami T A, ‘Treatment of Hemifacial Spasm with Botulinum Toxin.’, Muscle & Nerve, 15.9 (1992), 1045–49. 18. Heuser K et al. ‘Microvascular Decompression for Hemifacial Spasm: Postoperative Neurologic Followup and Evaluation of Life Quality’, European Journal of Neurology, 14.3 (2007), 335–40 <https://doi.org/1 0.1111/j.1468-1331.2006.01670.x>. 19. Herz N L, Yen M T, ‘Modulation of Sensory Photophobia in Essential Blepharospasm with Chromatic Lenses’, Ophthalmology, 112.12 (2005), 2208–11 <https://doi.org/10.1016/j.ophtha.2005.06.030>. 20. Malhotra R et al. ‘The Effect of Bangerter Occlusion Foils on Blepharospasm and Hemifacial Spasm in Occlusion-Positive and Occlusion-Negative Patients’, The Open Ophthalmology Journal, 4 (2010), 1–6 <https://doi.org/10.2174/1874364101004010001>. 21. ‘Botulinum Toxin Therapy of Eye Muscle Disorders. Safety and Effectiveness. American Academy of Ophthalmology’, Ophthalmology, Suppl (1989), 37–41. 22. Dutton J J, ‘Botulinum-A Toxin in the Treatment of Craniocervical Muscle Spasms: Short- and Long-Term, Local and Systemic Effects’, Survey of Ophthalmology, 41.1 (1996), 51–65. 23. Albanese A et al, ‘Pretarsal Injections of Botulinum Toxin Improve Blepharospasm in Previously Unresponsive Patients’, Journal of Neurology, Neurosurgery, and Psychiatry, 60.6 (1996), 693–94. 24. Mejia N I, Dat Vuong K, Jankovic J, ‘Long-Term Botulinum Toxin Efficacy, Safety, and Immunogenicity’, Movement Disorders: Official Journal of the Movement Disorder Society, 20.5 (2005), 592–97 <https:// doi.org/10.1002/mds.20376>. 25. Greene P, Fahn S, Diamond B, ‘Development of Resistance to Botulinum Toxin Type A in Patients with Torticollis’, Movement Disorders: Official Journal of the Movement Disorder Society, 9.2 (1994), 213–17 <https://doi.org/10.1002/mds.870090216>. 27. Defazio G et al. ‘Facial Dystonia: Clinical Features, Prognosis and Pharmacology in 31 Patients’, Italian Journal of Neurological Sciences, 10.6 (1989), 553–60. 26. Karapantzou C et al. ‘Frontalis Suspension Surgery to Treat Patients with Essential Blepharospasm and Apraxia of Eyelid Opening-Technique and Results’, Head & Face Medicine, 10 (2014), 44 <https://doi. org/10.1186/1746-160X-10-44>. 27. Benign Essential Blepharospasm Research Foundation <https://www.blepharospasm.org/> 28. Dystonia Society <https://www.dystonia.org.uk/> 29. Albanese A, Bentivoglio AR, Colosimo C, et al. Pretarsal injections of botulinum toxin improve blepharospasm in previously unresponsive patients. Journal of Neurology, Neurosurgery, and Psychiatry. 1996;60(6):693--4 30. Cakmur R, Ozturk V, Uzunel F, et al. Comparison of preseptal and pretarsal injections of botulinum toxin in the treatment of blepharospasm and hemifacial spasm. J Neurol. 2002;249(1):64--8 
 31. Jankovic J. Pretarsal injection of botulinum toxin for blepharospasm and apraxia of eyelid opening. J Neurol Neurosurg Psychiatry. 1996;60(6):704 32. Fayers T, Shaw SR, Hau SC, Ezra DG, British Journal of Ophthalmology, Changes in corneal aesthesiometry and the sub-basal nerve plexus in benign essential blepharospasm, November 2015

Dr Michelle Ting is a senior ophthalmology registrar at Moorfields Eye Hospital. She has a strong interest in oculoplastic surgery and works closely with Mr Daniel Ezra.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


     

      

      exciting new power unleashed against pigmentation from the worldâ&#x20AC;&#x2122;s leading pigmentation specialist

       


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The Role of Vitamin C in Skin Health Dr Helen Robertshaw and clinical educator Victoria Hiscock discuss the science and benefits of topical vitamin C, plus necessary considerations when choosing a vitamin C serum It is commonly recognised that vitamin C affects a wide variety of skin functions; therefore, it is essential to include when building skincare routines for our patients. Topical application of vitamin C to the skin can have a significant impact on skin rejuvenation, but understanding its many complexities is of upmost importance for successful results.

Benefits of vitamin C on skin The most abundant antioxidant in human skin, vitamin C,1 is a natural skin constituent and found at high levels in both the epidermis and dermis.2,3 L-ascorbic acid is the most biologically active and wellstudied form of vitamin C, so will be discussed in this article.4 Arguably, the most relevant free radical to ageing is ultraviolet radiation (UVR).5,6 UV-induced erythema and thymine dimer mutations (DNA mutations caused by UV radiation) that contribute to skin cancer are reduced by sunscreen.7 However, research has suggested that sunscreen only blocks 55% of the free radicals produced by UVR.8 Therefore, to optimise UV protection it is important to apply a powerful antioxidant as a second line of defence. When the skin is exposed to UV light it generates reactive oxygen species (ROS) such as the superoxide ion, peroxide and

singlet oxygen.9 Vitamin C protects the skin from oxidative stress by sequentially donating electrons to neutralise such free radicals. As a water-soluble molecule, this protection occurs within the aqueous compartments of the cell. In one laboratory study, 10% topical vitamin C showed a statistical reduction of UVB-induced erythema by 52% and sunburn cell formation by 40-60%.4 Widely promoted for its efficacy as an antioxidant, vitamin Câ&#x20AC;&#x2122;s essential role in collagen synthesis is often neglected. Topical L-ascorbic acid in concentrations between 5-15% has an antiageing effect by increasing type 1 and 3 pro-collagen messenger RNA levels in fibroblasts.10 Vitamin C is also required for the crosslinking of collagen fibres into its strong rope-like triple helix structure and acts as a co-factor for the enzymes prolysyl and lysyl

hydroxylase, which are responsible for stabilising and cross-linking the collagen molecules.11 Furthermore, it has been shown to inhibit matrix metalloproteinase 1 (MMP 1/ collagenase 1), which is responsible for the degradation of healthy collagen.12,13 Although many available studies use small sample sizes, they support vitamin Câ&#x20AC;&#x2122;s efficacy for the skin. One double-blind placebo-controlled study on 10 subjects using 10% topical vitamin C over a 12-week period showed a statistically significant reduction in photoaged scores and improvement in wrinkling in the vitamin C treated patients, compared with the placebo group.14 A significant improvement in wrinkles on skin histology and clinical appearance was also seen in another double-blind, placebo-controlled study using 5% topical vitamin C on 20 subjects over a six-month period.15 Vitamin C also plays a role as an antipigmentation agent. Vitamin C can decrease melanin production by interacting with copper ions at the tyrosinase-active site, which inhibits the action of the enzyme tyrosinase.16 One clinical study using 40 participants with melasma examined the effect of a topical formulation containing 5% vitamin C and a penetration enhancer, reporting a significant decrease in pigmentation caused by melasma after 16 weeks.17 Additionally, vitamin C is an effective antiinflammatory agent due to its inhibition of NFkB (nuclear factor kappa-light-chainenhancer of activated B cells), which is responsible for the production of a number of pro-inflammatory cytokines such as TNF-alfa, IL1, IL6 and IL8.4 Vitamin C contributes to immune defence by supporting various cellular functions and supports epithelial barrier function against pathogens. Vitamin C accumulates in phagocytic cells, such as neutrophils, and can enhance chemotaxis, phagocytosis and microbial killing. It is also needed for apoptosis and clearance of the old neutrophils from sites of infection by

Oral vs. topical vitamin C The absorption of vitamin C through the small intestine is limited by an active transportation mechanism and, therefore, only a finite amount is absorbed when taken orally, even in high doses.21 Furthermore, the bioavailability of vitamin C in the skin is inadequate when it is administered orally.4,10 Topical application of vitamin C will cross the epidermis due to its low molecular weight and at formulations with a pH of 3.5 or less, its penetration is enhanced.22 For these reasons, topical vitamin C is a useful addition to oral Vitamin C to promote skin health.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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macrophages. Vitamin C deficiency results in impaired immunity and a higher susceptibility to infections.18

Vitamin C and ageing Whilst young skin has an abundance of vitamin C, ageing causes its quantitative decline.3 In one study, intrinsically aged skin was shown to have 70% less concentration of several antioxidants, including L-ascorbic acid compared with young skin.12 Plants and animals are able to synthesise vitamin C from glucose; however, humans lack the enzyme L-glucono-gamma lactone oxidase required for its synthesis.19 UV radiation also contributes to the depletion of our natural vitamin C levels.20 For these reasons, we need to acquire vitamin C from external sources to attain its outstanding benefits.

Vitamin C in skincare The desire to formulate with L-ascorbic acid due to its multi-potentiality in combination with the fragility of its nature as a water-soluble molecule poses a significant challenge to formulators. In our clinical experience and opinion, a serum that stabilises the vitamin C, enhances permeability and is at the correct pH is necessary for best results. L-ascorbic acid serums that are stable and active will appear as a clear to straw-coloured liquid, which will turn an orange or brownish colour when exposed to air or light, an indication it has oxidised.23 When oxidised, the vitamin C is no longer helpful for the skin. Therefore, innovations must be made by manufacturers to protect L-ascorbic acid from oxidising, not only during the period of use by the patient, but also during the period between production and purchase. Some ways the stability of L-ascorbic acid can be maintained is by optimising the product’s pH. In a solution with a pH of 3.5 or less, the charge of the molecule is removed and cutaneous absorption can occur.22 The packaging material must also be considered – brown glass reduces the amount of light that reaches the solution. In the quest to keep L-ascorbic acid stable and active, formulators may also suspend it in an aqueous-free solution such as a silicabased product. Another technique used is to supply a long-term dose of vitamin C that is separated into a number of small bottles. Click release technologies can be used to keep the vitamin C separated from the suspension solution in powered form until the patient purchases the product and mixes the two at home.

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We recommend that practitioners make their patients aware of the oxidation process so that they can monitor their own products so to always ensure effective results. Importantly, they should make sure to replace the lid immediately after every application and keep the product away from direct sunlight.4 Measures can also be taken by formulators to maximise the efficacy of vitamin C. An example of one such measure is pairing with vitamin E, which potentiates its actions.24,25 Hydrophilic vitamin C also helps to regenerate vitamin E, a lipophilic antioxidant.4,10,26 Thus, vitamin C and vitamin E work together to protect the hydrophilic and lipophilic compartments of the cell.

Limitations to treatment Despite its powerful activity in the skin, there are minimal contraindications for the topical use of vitamin C. It is known to have an excellent safety profile.27 Its only limitation of use is a known allergy to the ingredient itself, which has been rarely reported.28,29

Vitamin C is essential for skin health The multi-faceted benefits of vitamin C make it an essential molecule for skin health and rejuvenation and as practitioners we should be educating our patients about its benefits. Avoid treating patients with vitamin C serums that oxidise in their bottles, turning a brownish colour while they are on the shelf or at home as they have no benefit to the skin. Dr Helen Robertshaw is a consultant dermatologist, Mohs surgeon and director and owner of Southface Skin Clinic, based in Dorset. With 20 years of experience in dermatology and an aesthetic and medical practice, Dr Robertshaw offers dermatology guidance in skincare and treatments. Victoria Hiscock has been teaching advanced skincare to dermatologists and aesthetic doctors for almost 15 years. She completed her NVQ in beauty therapy 16 years ago, specialising in skin health. She has a passion for cosmetic science and is currently clinical educator and brand spokesperson at skincare company AlumierMD.

REFERENCES 1. Compound Summary for CID 54670067, PubMed Open Chemistry Database, NIH U.S. National Library of Medicine. 2. Shindo Y, Witt E et al. Enzymic and non-enzymic antioxidants in epidermis and dermis of human skin. J Invest Dermatol 1994;102:122-24. 3. Rhie G, Shin MH et al. Aging- and photoaging-dependent changes of enzymic and nonenzymic antioxidants in the epidermis and dermis of human skin in vivo. J Invest Dermatol 2001;117:1212-17. 4. Talakoub L, Neuhaus IM, Yu SS. Cosmeceuticals. In: Alam M, Gladstone HB, Tung RC, editors. Cosmetic dermatology. Vol. 1. Requisites in Dermatology. 1st ed. Gurgaon: Saunders Elsevier; 2009. pp. 13–4. 5. Tyrrell RM. Ultraviolet radiation and free radical damage to skin. Biochem Soc Symp. 1995;61:47-53 6. Hekimi S, Lapointe J, Wen Y. Taking a “good” look at free radicals in the aging process. Trends in Cell Biology 2011;21(10)569-76. 7. Al Mahroos M, Yaar M et al. Effect of Sunscreen Application on UV-Induced Thymine Dimers. Archives of Dermatology 2002 Dec;138(11):1480-5. 8. Haywood R et al. Sunscreens Inadequately Protect Against Ultraviolet-A-Induced Free Radicals in Skin: Implications for Skin Aging and Melanoma? J Invest Dermatol 2006;121:862-68. 9. De Jager TL, Cockrell AE, Du Plessis SS. UV light induced generation of reactive oxygen species. Adv Exp Med Biol 2017;996:15-23 10. Traikovich SS. Use of Topical Ascorbic acid and its effects on Photo damaged skin topography. Arch Otorhinol Head Neck Surg 1999;125:1091–8. 11. Boyera N, Galey I, Bernard BA. Effect of vitamin C and its derivatives on collagen synthesis and cross-linking by normal human fibroblasts. Int J Cosmet Sci 1998 Jun;20(3):151-8. 12. Nusgens BV, Humbert P et al. Topically applied vitamin C enhances the mRNA level of collagens I and III, their processing enzymes and tissue inhibitor of matrix metalloproteinase 1 in the human dermis. J Invest Dermatol 2001;116:853–9. 13. Haftek M, Mac-Mary S et al. Clinical, biometric and structural evaluation of the long-term effects of a topical treatment with ascorbic acid and madecassoside in photoaged human skin. Exp Dermatol 2008;17:946–52. 14. Fitzpatrick RE, Rostan EF. Double-blind, half-face study comparing topical vitamin C and vehicle for rejuvenation of photodamage. Dermatol Surg 2002;28(3):231-6. 15. Humbert PG, Haftek M et al. Topical ascorbic acid on photoaged skin. Clinical, topographical and ultrastructural evaluation:doubleblind study vs. placebo. Exp Dermatol 2003;12(3):237-44. 16. Matsuda S, Shibayama H et al. Inhibitory effects of novel ascorbic derivative VCP-IS-2Na on melanogenesis. Chem Pharm Bull 2008;56:292–7. 17. Hwang SW, Oh DJ et al. Clinical efficacy of 5% L-ascorbic acid (C’ensil) in the treatment of melasma. J Cutan Med Surg 2009 Mar-Apr;13(2):74-81. 22 Carr AC, Maggini S. Vitamin C and Immune Function. Nutrients 2017 Nov 3;9(11). 18. Carr AC, Maggini S. Vitamin C and Immune Function. Nutrients 2017 Nov 3;9(11). 19. Naidu KA. Vitamin C in human health and disease is still a mystery? An overview. Nutr J 2003;2:7. 20. Shindo Y, Witt E, Packer L. Antioxidant defense mechanisms in murine epidermis and dermis and their responses to ultraviolet light. J Invest Dermatol 1993;100:260-265. 21. Farris PK. Cosmetical Vitamins: Vitamin C. In: Draelos ZD, Dover JS, Alam M, editors. Cosmeceuticals. Procedures in Cosmetic Dermatology. 2nd ed. New York: Saunders Elsevier; 2009. pp. 51–6. 22. Pinnell SR, Yang H et al. Topical L-ascorbic acid: percutaneous absorption studies. Dermatol Surg 2001;27:137-42. 23. Pumori Saokar Telang, Vitamin C in dermatology, Indian Dermatol Online J. 2013 Apr-Jun; 4(2): 143–146. 24. Murray JC, Burch JA et al. A topical antioxidant solution containing vitamins C and E stabilized by ferulic acid provides protection for human skin against damage caused by ultraviolet irradiation. J Am Acad Dermatol 2008;59:418–25. 25. Telang PS. Vitamin C in dermatology. Indian Dermatol Online J 2013 Apr-Jun;4(2):143-6. 26. Lin JY, Selim MA et al. UV photoprotection by combination topical antioxidants vitamin C and vitamin E. J Am Acad Dermatol. 2003;48:866-74. 27. Elmore AR, Final report of the safety assessment of L-Ascorbic Acid, Calcium Ascorbate, Magnesium Ascorbate, Magnesium Ascorbyl Phosphate, Sodium Ascorbate, and Sodium Ascorbyl Phosphate as used in cosmetics, Int J Toxicol. 2005;24 Suppl 2:51-111. 28. Belhadjali H, Giordano-Labadie F, Bazex J. Contact dermatitis from vitamin C in cosmetic anti-aging cream. Contact Dermatitis. 2001 Nov;45(5):317 29. Swinnen I, Goossens A. Allergic contact dermatitis caused by ascorbyl tetraisopalmitate. Contact Dermatitis. 2011 Apr;64(4):241-2

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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A summary of the latest clinical studies Title: Improvements in the Perception of Facial Attractiveness Following Surgical Aesthetic Treatment; Study Based on Online Before and After Photos Authors: Przylipiak M, Przylipiak J et al. Published: Journal of Cosmetic Dermatology, December 2018 Keywords: Botulinum toxin, attractiveness, blepharoplasty, face, facelift, lip augmentation Abstract: Aesthetic surgery procedures such as lip augmentation, eyelid correction, face-lifting, or Botulinum toxin treatment for lines and wrinkles are an important part of cosmetic surgery. The aim of the study was to estimate improvement in appearance following plastic surgery using modern collective intelligence methods of validation. A total of 108 photographs showing 54 patients prior to and following cosmetic surgery were downloaded from internet web presentations of several unnamed plastic surgeons. The same number of photographs depicted each of the four investigated areas of treatment – 26 lip enhancement, 26 blepharoplasty, 26 face-lift, 26 botulinum toxin injection. Attractiveness of depicted individuals was assessed by 167 observers. Each photograph was judged separately. Blepharoplasty produced the most remarkable improvement in attractiveness amounting to 32.79 (SD ± 26.35). Improvement following Botulinum toxin treatment stood at 30.29 (SD ± 24.55), whereas face-lifting produces improvement of 28.70 (SD ± 22.76). Improvement following lip augmentation was estimated at 12.70 (SD ± 29.8). Highest Spearman’s rank correlation coefficient was obtained for face-lift and Botox (0.24 and 0.22, respectively). Blepharoplasty, face-lifting, and Botulinum toxin deliver a significant improvement in facial attractiveness. Additionally, face-lifting and Botox are distinguished by a high level of reproducibility. Our results indicate that lip augmentation is a treatment with a statistically significant, but less marked improvement in attractiveness. Title: Enhanced Skin Targeting of Retinoic Acid Spanlastics: InVitro Characterization and Clinical Evaluation in acne Patients Authors: Nabil Shamma R, Sayed S, et al. Published: Journal of Liposome Research, December 2018 Keywords: Penetration enhancer, retinoic acid, acne, dermatology Abstract: Acne vulgaris is the most common dermatological disorder affecting millions of individuals. Acne therapeutic solutions include topical treatment with retinoic acid (RA) which showed a good efficacy in treatment of mild and moderate cases. However, the high prevalence of adverse events, such as skin dryness, shedding and skin irritation affects the patient convenience and obstruct the acne treatment. Thus, the objective of this paper was to produce Span 60 based elastic vesicles enriched with penetration enhancers, and study their influence on the delivery of RA and its skin irritation. RA-loaded nanovesicles, enriched with Transcutol/Labrasol, were made using the thin film hydration technique, and assessed for entrapment efficiency, particle size and zeta potential. The optimized RA-loaded nanovesicles (composed of Span 60-Tween 20, and Transcutol) were morphologically assessed via transmission electron microscopy. Moreover, RA deposition into newborn mice

skin was assessed in vitro under non-occlusive conditions, where the optimized RA-loaded nanovesicles showed 2-fold higher RA deposition in the skin compared to the corresponding one lacking Transcutol. The optimized RA-loaded nanovesicles incorporated into 1% carbopol gel was evaluated for in-vivo clinical performance in acne patients, and showed appreciable advantages over the marketed formulation (Acretin) in the treatment of acne regarding skin tolerability and patient’s compliance. Title: Post Filler Ecchymosis Resolution with Intense Pulsed Light Authors: Narurkar V Published: Journal of Drugs in Dermatology, December 2018 Keywords: Dermal filler, side effects, intense pulsed light Abstract: Bruising after dermal filler and neuromodulator injections is a common side effect and can have durations of 1 to 2 weeks. While it ultimately resolves, faster resolution can produce better outcomes for patients and also make patients more likely to return for future treatments. We report the successful reduction in bruising following injections of fillers with an intense pulsed light source. We also documented the onset of action of bruising resolution with serial photographs. Resolution started within the first hour of treatment and continued rapidly over 48 hours. This is the first-time reported study of resolution of bruising from injectables with intense pulsed light. Patient satisfaction is improved when such adverse events are minimized. Title: Six Years of Experience Using an Advanced Algorithm for Botulinum Toxin Application Authors: Casabona G, Kaye K, et al. Published: Journal of Cosmetic Dermatology, December 2018 Keywords: botulinum toxin, facial rejuvenation, treatment algorithm, treatment guidelines Abstract: Botulinum toxin (BTX) products continue to be widely used for facial rejuvenation. Variables to consider prior to BTX treatment include the anatomical area to be treated, gender, muscle mass, ethnicity, skin thickness, and the effects of aging. This paper will describe a treatment algorithm which has been developed for facial rejuvenation to help physicians easily and systematically customize BTX treatment, and to describe its use in a large number of patients. Prior to treatment, digital images of patients were obtained while relaxed and while forming different facial expressions. This information was used to plan the depth, dose, and location of BTX injections (onabotulinumtoxinA; Botox; Allergan, Inc). Dilution was 100 U of BTX to 1 mL 0.9% preserved saline. Injections were performed with 30 U insulin syringes and 30-gauge needles. The treatment algorithm described here has been used by the author for facial rejuvenation for more than 5 years. It was originally based on published guidelines; however, by carefully noting treatment outcomes, the number and location of injection points and the dose of BTX used have been modified to create the current treatment system. Published guidelines for the use of BTX are an excellent starting point for clinicians with little experience; however, each practitioner is likely to develop their own algorithm for achieving good facial rejuvenation outcomes.

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Capitalising on Celebrity Trends Julia Kendrick explores how, when and why to get on board with celebrity trends and how to translate this into meaningful business outputs The aesthetic specialty sometimes seems to have a split personality – on one side is the medical, ethical approach that many of us strive to represent in our businesses, and on the other is the frivolous, extreme and often celebrity-driven ‘fad’ elements that flood our Instagram feeds. There is no doubt – thanks to social media – that we are now firmly in an era of ‘society-driven’ medicine, where public and media perceptions of our industry are locked in a symbiotic cycle; one feeding and driving the other. Like it or not, celebrity culture and the media now influence many of the trends (and patient demands) seen in aesthetic practice today, and knowing how and when to engage with this can be a critical tool to keeping your clinic ahead of the curve and driving sales.

Celebrities, the media and cosmetic surgery In the past, cosmetic surgery and medical aesthetics only belonged in the realms of Hollywood and were often secretive or seen as only for the wealthy, setting those who undergo treatment apart from the crowd (and often not in an aspirational way). Switch to today and the huge shift towards minimally-invasive products and procedures has enabled cosmetic interventions to be within the grasp of the ‘average’ person with desired outcomes shifting towards looking good, not ‘done’. We still have celebrity influencers, but these are now much more likely to be social media ‘stars’ such as Kim Kardashian.

From Instagram to your waiting room With ‘selfies’, Instagram and Snapchat filters now driving many beauty and fashion trends, practitioners face a double-edged sword when it comes to jumping onto a trend bandwagon. Incorporating a strategic trend-led treatment or offer into your clinic’s PR and marketing can help you take advantage of a swell of existing patient interest and attention. This can be funnelled effectively into bookings, brand awareness and PR opportunities. What is sensational one minute can often be standard procedure the next. For example, the infamous viral photo of Kim Kardashian’s bloodied face – the start of the Vampire Facelift – caused initial shock, yet platelet-rich plasma is now standard practice in many clinics. However, beware of the ‘whatever next’ bandwagon as occasionally these trends are just that – flashes in the pan, not founded on proven products, or ethical practice. Make sure you take an educational role in helping prospective patients separate the ‘new and interesting’ from the bizarre and irresponsible.

Riding the wave of celebrity trends The first key element of successful celebrity and trend-led marketing is to identify and monitor those celebrities who will appeal to your clinic demographic. Take some time to check out your customer’s overall age profile and the most requested procedures in your clinic before creating a shortlist of celebrities who might appeal to that demographic (see Figure 1 as an example). A Patient age

Most requested procedures

20-30

Lip, augmentation, botulinum toxin, body contouring

40-50

Full-face dermal filler treatments, laser facials threads

Other profile considerations

Socio-economic status, previous aesthetic treatments

Figure 1: Example of patient and celebrity brainstorm

Possible celebrities to monitor Kylie Jenner Holly Willoughby Kim Kardashian Kate Winslet Cate Blanchett Priyanka Chopra

mix of British celebrities and other cultures is also useful to draw up. You could also run a quick survey among your patients to identify the top three celebrities they find most beautiful or aspirational, in return for a small reward or a chance to win a small gift set. This is also great for customer engagement and is very useful for your marketing campaigns! Once you know the kind of celebrities who will appeal to your patients, you can begin monitoring social and online sources for news and ideas related to these particular individuals and their beauty ‘secrets’ – or for broader beauty stories and trends, which you could link to your target celebs. This can easily be done by setting up Google alerts for your target celebrities, so you are the first to hear of any stories involving them, or key search terms like ‘facials’ or ‘fillers’. Another option is to use Twitter platform like Tweetdeck,1 where you can create search columns for specific users, or hashtags such as #dermalfillers or #beautytrends. You only want to highlight aspirational trends – so it goes without saying to steer clear of anything that appears extreme, unsafe or where the celebrity is ‘hiding’ their treatment. Being ‘papped’ coming out of a clinic, or showing off bizarre after-effects of treatment (e.g. the Gwyneth Paltrow ‘cupping’ story),2 is not perhaps the best way to market your own offerings. Look out for celebrity interviews, news and magazine articles and social media posts for inspiration about upcoming trends and what celebrities are talking about.

Creating marketing opportunities The trouble with trends is that they often come and go, so your marketing must be nimble to capitalise on short-term opportunities. For example, if a celebrity reveals in a magazine interview that they ‘swear by’ a certain skincare brand, facial, or treatment which you either have in-clinic, or are about to launch, or is closely linked to your treatment offerings, this could be utilised as a trend-driven marketing opportunity. Examples of marketing celebrity trends Create an e-blast to your customers This should ideally be done on the day, or the day after the story breaks. Keep the email short, sweet and visual. Highlight the celebrity story and use an image of the celebrity – you should get these images from a stock photo library and not just pull them from the internet as you could be in breach of copyright laws.3,4 In the e-blast, tell your customers about the trend, what

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


NEW & EXCLUSIVE FOR 2019! THE SALLY DURANT DIAMOND DIPLOMA IN SKIN HEALTH, COSMETIC DERMATOLOGY AND REMEDIAL AESTHETIC PRACTICE This course will be delivered under the personal tutelage of Sally Durant and there will be just two cohorts per year (March and September) with only 12 students in each. WE ARE ENROLLING NOW FOR MARCH 2019 COMMENCEMENT The Sally Durant Diamond Diploma incorporates the CIBTAC Level 4 Diploma in Advanced Skin Studies and Aesthetic Practice, while additionally embracing a significantly wider curriculum and attention to detail. COURSE CONTENT Core Knowledge for Aesthetic Practice The Principles and Practices of the Medispa Sector Advanced Histology and Skin Science Advanced Skin Health Assessment Nutrition for Skin Health The Physiology and Practice of Chemical Skin Peeling The Physiology and Practice of Micro-Needling Skin Blemish Removal by Thermolysis and Cryotherapy Cosmetic Dermatology An introduction to Laser and Light Therapies Combination Aesthetic Therapies for Remedial Skin Care and Body Contouring • The Principles of Medical Aesthetic Procedures • Cosmeceutical Science and Product Formulation • Business Development For Aesthetic Practice • • • • • • • • • • •

“I will be personally teaching and mentoring the students who enroll on this diploma and will be asking for a high level of commitment to study together with exemplary professional standards to facilitate the achievement of excellence... In order to enable me to deliver to you the optimal level of teaching and training, the time you will spend within the training centre, and the coursework schedule you will need to complete, are both greater than that for the Level 4 qualification alone. This is to ensure that you leave the course not only with the most comprehensive knowledge and skill, but with a superior understanding of the intricacies of skin health and of the breadth of aesthetic practice.”

TO APPLY FOR THIS UNIQUE SPECIALIST TRAINING PROGRAMME PLEASE CALL OR EMAIL CAROLINE WALTON 01527 919880 / caroline@sallydurant.com


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the celebrity has said and then link it to your relevant clinic treatment or offering. For extra oomph, you might want to create a special treatment offer with a bespoke code – subject to conditions. If possible, create a temporary landing page on your website, which just includes the same information as the e-blast to direct web traffic from social posts – this allows you to assess the engagement with each trend-driven activity. Create a post or mini video for social media Video formats get the highest engagement on social channels, in fact, social video generates 1,200% more shares than text and images combined.5 Produce a video about your expert advice or opinion about the latest celebrity trend; remember to keep the focus very targeted and don’t go off track. This positions you as someone with knowledge about that particular trend. At the end of your video you should also add links to your blog or the treatment page on your website, this can help drive traffic and focus bookings. Alternatively, a social media post linking to the original story or celebrity image, with the caption highlighting your special offer is a rapid way to capitalise on a celebrity trend. Always make sure you include the relevant hashtags so users seeking this information can find you easily. For Instagram, encourage your followers to go to the link in your bio (that connects to your special landing page or blog) or to swipe up to book (this feature is only available in Instagram if you have over 15K followers).6 Write a blog This is the opportunity to provide more education to your patients about the trend or treatment and give your opinion (positive or negative) alongside your recommended treatment focus or products for your patients. Beware of speculation – limit your comments to verifiable trends or a statement from a celebrity interview. Commenting on what someone ‘might’ have done is a potential defamation situation,4,7 so stick to celebrity interviews or direct quotes. Promote the blog post on your social channels and ensure you use the celebrity picture with a snappy title – such as ‘The Secret Behind Kate Winslet’s Glowing Skin’. Blogs not only create engagement among existing and potential patients, but they could get you on the radar of local press or. bloggers and social media influencers looking for a credible source to ask about the latest ‘must have’ treatment – thereby building your reputation and increasing exposure.

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Include in your newsletter To maximise these methods, re-use the above in your monthly clinic newsletter. As long as your newsletters are relatively frequent, the ‘trend’ should still be in the public eye – but if in doubt, Google Trends is a great tool to monitor search volumes for a particular topic or celebrity in your country, so you can check that you still are ‘on trend’!8 You can include the video link in your newsletter, a summary of the blog post, or include a ‘last chance’ reminder of your e-blast special offer. The key to all this is multi-channel consistency – don’t rely on just one method to drive through the sales – link as many as possible, be that through the website, newsletters, social posts and blogs. In-clinic marketing Don’t forget your in-clinic marketing as well. You can post your videos talking about the latest celebrity trends onto your clinic TV as this can be easily updated, or even create eye-catching posters to link the celebrity/ trend to your in-clinic offerings in the reception area. Remember to ensure that your in-clinic marketing stays relevant and replace with the latest information once the trend changes.

A word of caution If you are able to quickly and effectively position yourself as an early adopter of the latest trend treatment, you could be the ‘first’ or ‘only’ one to get on the bandwagon, which can be marketing gold. In order to do this, your PR channels (website, social media, traditional press) need to be responsive, rapid and consistent – profiling your offering and optimised to take advantage of the wave of media coverage, Google searches and social media hashtags linking you to the new trend. However, being a trend-setter can be a double-edged sword if you align yourself and your business to a product or procedure that hasn’t been properly researched or tested. An example would be Macrolane – which went from rave reviews for lunchtime ‘boob jobs’, to women left with crippling health problems.9 In addition, there has been much commentary on the rise of body dysmorphia linked with aesthetics and cosmetic surgery.10 There are increasing levels of anxiety and depression among patients, particularly Millennials, which are being linked to social media use and how they appear on platforms like Instagram versus real life.11 Patient education and responsible marketing remain paramount,

so always ensure you include your expert advice and opinion when utilising any broader industry or beauty trends in your clinic marketing.

Conclusion While celebrity trends come and go, they can provide highly effective marketing opportunities if you can create the content quickly and distribute across multiple channels. The bottom line is that as responsible, reputable practitioners you need to decide which trends are truly well-founded in medicine and quality application before advocating them to your patients. Aesthetics is a hotbed of innovation, which means there will be no shortage of these exciting opportunities. But, as long as you look under the surface of these trends, you should be able to effectively navigate for icebergs and minimise risks that could take down your business and hard-won reputation. Julia Kendrick is an awardwinning communicator, specialising in medical aesthetic and healthcare PR. Kendrick also created the E.L.I.T.E. Reputation Programme – an online PR and marketing training designed specifically for aesthetic practitioners. REFERENCES 1. Twitter, How to use TweetDeck, 2018. <https://help.twitter.com/ en/using-twitter/how-to-use-tweetdeck> 2. Amy Lafayette, The Healing Power of Cupping, <https://goop. com/wellness/health/the-healing-power-of-cupping/> 3. Gov.Uk, Intellectual Property Office, Copyright Notice: digital images, photographs and the internet, 2015. <https://assets. publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/481194/c-notice-201401.pdf> 4. Fiona Clark, How to Avoid Breaching Publishing Laws, Aesthetics journal, 2018. <https://aestheticsjournal.com/feature/ how-to-avoid-breaching-publishing-laws> 5. Mary Lister, WordStream Blog, 37 Staggering Video Marketing Statistics for 2018. <https://www.wordstream.com/blog/ ws/2017/03/08/video-marketing-statistics> 6. Bright Spark, How To Turn Your Logo Into A Button On Instagram Stories, 2018. <https://www.brightspark-consulting. com/instagram-stories-tip-swipe-up/> 7. Legislation.gov.uk, Defamation Act 2013, <http://www.legislation. gov.uk/ukpga/2013/26/enacted> 8. Hallam, How to use Google Trends to Gain a Competitive Edge, 2016. <https://www.hallaminternet.com/google-trendsintroduction-business/> 9. Maddii Lown, Doctors pleased over end of Macrolane breast injections 2012, BBC. <http://www.bbc.co.uk/newsbeat/ article/17813817/doctors-pleased-over-end-of-macrolane-breastinjections> 10. Anthony Bewley & Dimitre Dimitrov, Recognising Body Dysmorphic Disorder in Aesthetic Practice, 2015. <https:// aestheticsjournal.com/feature/recognising-body-dysmorphicdisorder-in-aesthetic-practice> 11. Amanda MacMillan, Why Instagram Is the Worst Social Media for Mental Health, Time, 2017<http://time.com/4793331/instagramsocial-media-mental-health/>

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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developed a system which helped them to navigate their way through it. Below I discuss my DEPTH protocol, which focuses on five key areas of an aesthetic business owner.

Building Success in Aesthetics Business coach and author Alan Adams shares his step-by-step protocol for establishing what’s important to you and your clinic and how to build upon your success It’s natural to compare yourself to others, particularly in such a niche market like aesthetics. Sometimes it can feel like your competitors are doing so much better than you, all while making things look so easy, with a big list of happy patients and a growing bottom line. Yet many clinics, like any business, can struggle to grow their portfolio, often face pressures with the day-to-day management and operations, experience problem staff and a crippling workload. In this article, I discuss how important it is to define what success means to you and how you, as an aesthetic professional, can build on this using my trademarked protocol, DEPTH.

Defining success As with any individual who comes to your clinic for treatment, success to one aesthetic professional will be completely different to another, and it ultimately comes down to what’s important to you on a personal level – outside of the business. It might be that you want an award that recognises your contribution to your industry and to your patients, or you might see success as being financially free and having more time. You might be a self-starter in the industry

whose idea of ultimate success is building a clinic with a £5 million turnover, or success to you may be seeing a patient’s life change because of the work that you have done. Whatever it looks like, it’s about turning your dream into a reality and reminding yourself why you started out in aesthetics in the first place. But despite many individuals across all areas of business having the biggest, boldest ideas of personal success, many don’t get there because they haven’t put in the effort to make things happen or they simply don’t know where to start. In this hugely competitive sector, it’s vital that not only do you have a clear idea of what success is to you, but that you don’t lose sight of it, and you work on the small things every day. Many of my clients have experienced some difficulty in building success, which is why I

D is for destination This is very much the ‘why’ and it comes first because it focuses on you, your life, and your dreams, as well as the life that you want your family to have. I often ask my clients to think about the type of house they want to live in one day, how many days a week they want to work, what car they want to drive, how much family time they want, and what type of hobbies and personal interests they want to have. It’s critical to get this absolutely nailed, and to develop a very clear picture of the end goal. Not only does it keep us motivated when we’re en route, but it also helps us to understand where we are right now, and what needs to be done to help us get to our destination. What amazes me in terms of general business, is how many owners make the mistake of not having this end goal absolutely crystal clear. To make your destination stick, figure out what motivates you the most – some people are more visually-stimulated so will benefit from seeing it in front of them every day on a white board, others will find that writing it down and re-reading it is easier. Whatever works best, use your calendar to prompt you to revisit it often and remind yourself why you’re doing what you’re doing. E is for exploration This is about understanding the resources and support you have available if you need them – whether it’s skills, expertise or product, or extra resources – as well as what you might need but don’t currently have. During some of my recent keynote speeches at industry events, I’ve used the analogy of Polar explorers Captain Robert Scott and Roald Amundsen (it’s one that US author Jim Collins famously referenced). Given the same level playing field, setting off at the same time, and experiencing the same weather conditions, a race began between

I tell my clients to make appointments with themselves and to treat this appointment as the most important one in their calendars

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Captain Robert Scott and his party, and Roald Amundsen and his men, to become the first humans ever to reach the South Pole.1 Roald and his men had beaten Captain Scott and his party to the pole 34 days ahead of them, despite setting off only days apart. Feeling depleted having seen the flag already there, Captain Scott and his men began the gruelling 700 mile return journey, with everyone exhausted, cold, and lacking the appropriate supplies. And despite a herculean effort, Scott and his party died just ten miles short of their primary food depot.1 Why is this relevant? Well, it’s about understanding the options and identifying how you’re going to get to your destination. For example, unlike Scott, Amundsen had gone the extra mile to ensure he picked the very best men for the expedition. He had planned for everything going wrong and considered every eventuality, putting the appropriate provisions in place – which Scott didn’t. And, he had even invested time and money to visit the North Pole beforehand to live with native people and understand the options and survival techniques for living in the cold.1 Like a lot of clinic owners, Scott had made assumptions based on his personal experiences and unfortunately, those assumptions cost the lives of him and his team. Luckily as clinic owners you won’t lose your life, but you may end up not living the life you intended to when you set up. I find that every problem in a business, whether it’s related to marketing, sales, staff or product, has almost always been solved by someone else already. I’m still shocked by the notion that an aesthetics professional, having gone through an extensive amount of training to become qualified and building their reputation over time, will spend tens of thousands on a new piece of equipment but will not invest time and money in learning how to run a commercially-effective clinic. If you don’t know what questions you need to be asking yourself about what you need help with, ask someone who does – it’s not seen as a weakness, and it’s impossible for you to know everything. One client I’m working with has struggled to get patients through the door, and it turns out that they are on their fourth website. I’d reviewed it, and noticed that the latest version, as well as those before it, lacked the hugely important stuff, such as a call to action on each page, news and blog section, share buttons, biographies and downloadable guides for patients to read before they make their decision to purchase. If you’re running an aesthetics clinic,

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it’s important to remember that it is still a business so get to know about how marketing, sales, lead conversions and websites if you can. P is for plan You’ll need to devise a solid business plan, but not the kind of cumbersome document that makes a loud bang when it hits the table. A well thought-out and valuable plan is one that is around three or four pages long, and where you have your objectives clearly outlined across every single area of your business. For example, it needs to clearly detail your turnover goal in one, three and five years, how many patients and treatments that equates to, the staff that you might need to service these patients (new and existing), and when and how many people you need to employ. Every ounce of planning matters here, including training and development, as this is the part where you will retain your competitive edge, or establish one if you don’t yet have your niche. Once you have your plan, you must make the time to review it regularly in order to stay motivated and on-track. I tell my clients to make monthly appointments with themselves so that they can look over their plan, and to treat this appointment as the most important one in their calendars. T is for tactics Next, you need to deliver on the plan and that’s where the tactics come in. These are specific actions that you and your team need to undertake to make sure that you hit every milestone and ultimately make headway for your final destination. Break each task down into bitesize chunks. Add deadlines and figure out who’s responsible for making each task happen – remember, it’s not all on you as the person heading it all up. For example, one objective may be that you need to relaunch your brand and freshen up the clinic. The tasks to be broken down might include contacting a number of designers to obtain quotes for a new logo and website update, working with printing suppliers, updating your customers, setting up a new strategic marketing and sales plan and funnel, and then tracking your results. You don’t need to do all of these personally – delegate or outsource, whichever enables you to focus on steering the ship and keeping your eye on the destination.

financial health. I teach my clients to track and measure their ‘numbers’ like clockwork, and to know their margins and break-even points. Most financial health reviews can be assessed by four or five figures. You can see how well you’re performing by looking at your turnover and profit, as well as incomegenerating numbers such as your number of leads, your conversion ratio of these leads turning into patients, how often they return to you, and how much their average spend is. Focusing on increasing these even by just 10% can have a huge impact on your turnover. Marketing and sales might not come naturally to someone in the aesthetics field, however their importance to your clinic shouldn’t be underestimated. As an example, you might currently have 84 patients and you have 100 additional leads, with a conversion rate of 25% – this will give you 109 patients. However, through your marketing and sales, if you were to increase your current number of leads from 100 to 110 (10% rise), and increase your conversation rate from 25% to 27.5% (2.5%) – you will see 114 of patients. Then, increase your average number of purchases in one year from 6.1 to 6.7 (a 10% rise). And finally, your average purchase value from £230 to £253 (again, 10%). These small and absolutely achievable increases could see your turnover could go from £152,927 to £235,970 – that’s a 54% uplift!

Conclusion It may sound like a lot of work while you’re in a full-time business, but these are all super simple exercises to help you set out your direction and work on your business instead of being wrapped up in the day-to-day operations. After all, everyone deserves to have a business that serves us how it should and how we expect it to, where we enjoy working every day and where we feel fulfilled. Alan Adams is an awardwinning business coach and bestselling author. The publication of his third book, The Beautiful Business: Secrets to Sculpting Your Ultimate Clinic, sees him focus specifically on the medical, cosmetic and aesthetic clinic sector, sharing advice and guidance with the aim of revolutionising clinic turnover, patient retention and overall growth. REFERENCES 1. Royal Museum of Greenwich, The race to the South Pole <https://www.rmg.co.uk/discover/explore/race-south-pole-1911>

H is for health Finally, the last part of creating DEPTH in your clinic is to give thought to your clinic’s

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Approaching Complication Claims Law firm partner Emma Galland explains the different types of claims that could arise post complication and advises on ways to deal with them It is an unfortunate fact that no matter how diligent and experienced a practitioner is, complications can occur with any procedure. This, combined with the socalled litigation-culture, and increasing patient expectations, means that most practitioners will find themselves dealing with a complication, complaint or claim at some point in their career. It’s important that practitioners have a clear process in place to deal with complications if they do occur and, where early resolution is not possible, know how best to manage any consequential refunds/claims. This article explains some of the avenues of recourse a patient may have following a complication, and the key steps practitioners can take to deal effectively with the consequences.

What is a complication? Broadly speaking, and for the purposes of this article, a complication is any event that was not anticipated by the patient/practitioner resulting from a procedure, treatment or illness. In my opinion, to deal most effectively with a complication, practitioners should be aware of the subjective impact of it on the patient and be mindful of how that patient’s individual circumstances will affect their response to it. For example, a patient who lives alone in a remote area, is likely to find that a complication affecting mobility will have a greater impact than one who lives in a city with family close by. Dealing efficiently with complications as soon as they arise, may, ultimately, avoid matters from escalating into a serious complaint or claim, which could in turn damage your reputation and your business. While it is not possible to identify all possible courses of actions for patients following a complication, I find that the most frequent outcomes include: 1. Ex gratia payment (out of goodwill) 2. Litigation claim 3. Claim by a credit card company The professional and statutory duty of candour1 will also be engaged following a

complication and, for that reason, we deal with a practitioner’s obligation arising from that duty first, discussed below. Following a complication, it is also important to consider the duty to notify insurers and seek their approval to any steps proposed to deal with it.

The law: duty of candour The duty of candour applies to both individuals (the professional obligation) and organisations registered with the Care Quality Commission, referred to from now on as the CQC (the statutory obligation).2 It is worth noting here that due to differentiating laws in Scotland and Ireland, this would be different again. As I am qualified in England and Wales, I will be discussing these areas specifically. Practitioners who are not registered with the CQC may not be required to comply with the statutory obligation. Regardless, however, those practitioners who are registered with a professional body should still comply with their professional obligation. Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 20142 requires providers to be open and transparent in the event of a complication. Specifically, in the event of a notifiable safety incident (NSI), explained below, the registered person/provider must, as soon as is reasonably practicable, notify the patient, offer an apology and investigate the NSI.3 It is a statutory requirement to provide an apology. This is not the same as an admission of liability – which should not be given without the specific agreement of the insurers. The apology should be an acknowledgement that something unexpected occurred which has impacted upon the patient. The notification should be made orally initially, where possible, and followed up in writing (see below). A NSI is an event with unintended/ unexpected consequences which may, in the opinion of the registered provider or registered person, have caused death, severe harm, moderate harm or prolonged psychological harm of at least 28 days.3

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Moderate harm is defined as harm that requires a moderate increase in treatment, and significant, but not permanent harm. A moderate increase in treatment is defined as ‘an unplanned return to surgery, an unplanned re-admission, a prolonged episode of care, extra time in hospital or as an outpatient, cancelling of treatment, or transfer to another treatment area (such as intensive care)’.2 This may include additional follow-up treatment such as injecting hyaluronidase following a lip filler complication where nodules are present from the initial treatment. It is important to remember that an incident may be a NSI even if it is unclear what, if any, harm has been caused. The threshold for meeting this requirement is law – if there is any suspicion that the requisite harm ‘may’ have been caused by an unexpected/ unintended incident, the practitioner should consider notifying the patient in this way. This situation may arise where, for example, a complication occurs. The provider must follow up the NSI notification in writing, including details of the investigation that will take place, and the likely timescales. At its conclusion, the patient must be advised either orally (with a clear record of any conversations) or in writing, of the outcome of the investigation. If the registered person/registered provider breaches the statutory duty of candour (or is unable to demonstrate that the statutory duty has been complied with – for those practitioners who are registered with the CQC), the CQC can impose a fine of up to level four of the standard scale (currently £2,500) per offence.4 If the registered person/registered provider can demonstrate that all reasonable steps were taken to comply with the duty of candour, this may prevent any sanctions. It is therefore important that registered providers/registered persons keep careful documentation of any notifications both orally and in writing.

Ex gratia payment An ex gratia payment is a payment made ‘out of goodwill’, as per its Latin translation. By this I mean, when there is no obligation on the practitioner to pay it. As such, it is up to the practitioner to decide if they would like to make an ex gratia payment as a result of a complication. This kind of payment is often made, for example, to recompense the patient for the costs of the treatment, particularly if the complication has meant that the treatment was unsuccessful. While there may be not always be an

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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obligation to do so, prior to offering this kind of payment, it is advisable to undertake a full investigation to ensure that the payment is justified. Likewise, while an ex gratia payment is usually paid by the practitioner/clinic, rather than through an insurance policy, it is still important to seek the insurer’s approval to making the payment before doing so. In my experience, this will ensure that any future claim is not prejudiced and/or that insurance cover is not invalidated. An ex gratia payment should be made outside of any formal court proceedings and progressing in this way may be preferable to avoid unnecessary legal costs being incurred. That said, I believe that it is advisable to make the offer (in writing) of the ex gratia payment as full and final settlement to avoid any litigation proceedings in the future, and to ensure that this proviso (that the payment is made in full and final settlement) is clearly set out. This approach can be successful where there is a clearly defined amount which the patient may be able to claim (for example a refund on the cost of treatment). If the claim is for an uncertain sum of money (e.g. for pain and suffering) and/or is for a substantial sum of money, offering an ex gratia payment may not be advised. Legal advice and/or approval from your insurers should be sought.

The law: litigation claims Broadly speaking, if a negligence claim is made, a clinic/practitioner’s insurers will be involved in managing the claim and may instruct solicitors to act for the clinic/ practitioner. The explanation below is therefore included by way of background. If a negligence claim is made, there are a number of requirements that must be met for it to be successful. Firstly, the person bringing the claim, the claimant, must show that the person/ organisation against whom the claim is brought, the defendant, owed them a duty of care. In cases involving medical treatment, it is broadly accepted that a duty of care is owed to patients by the medical practitioner/ organisation, and this duty of care has recently been extended such that it may, in some circumstances, also be owed by administrative members of staff (which may include, for example, the reception team) within the organisation. Secondly, having confirmed that the duty of care is owed to a patient, that duty of care must have been breached. The breach may have occurred in a number of ways but, in general terms, the claimant must show that

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the practitioner’s actions were not those of an ‘ordinary and competent’ practitioner acting within the same speciality, in accordance with the Bolam test.5 This test was later refined in the Bolitho case,6 which states that the analysis of the ‘ordinary and competent’ practitioner should be able to withstand logical analysis. For example, simply having supporting evidence is not enough. The supporting evidence must be able to stand up to challenge. It is often thought that the test for assessing a claim stops at this point: if breach of duty has been established, then surely the claimant is entitled to damages. However, there is a further element; the claimant must prove that the breach of duty has caused them harm. This harm must flow from the breach of duty and not be merely incidental to it, this is referred to as the ‘causation’ test.9 For example, if a complication arose during a procedure (such as unexpected bleeding), if there was no breach of duty causing that bleeding and/or any breach of duty did not cause the unexpected bleeding, a claim for negligence would fail. If the above three elements are met, damages will be awarded. It is important to remember that in England and Wales, damages are limited to putting the claimant in the position they would have been in had the breach of duty/incident not occurred. As well as reimbursing the patient for the treatment paid for, this will also include damage for the harm incurred. If the patient suffered from facial scarring as a result of the negligence, for example, the patient may also be able to claim in the region of £7,270-£23,980 based upon the Judicial College guidelines.7

Claim by credit card company Finally, if the patient considers that they have a valid claim, and paid for their procedures using credit (such as a credit card), they may be entitled to bring a claim under section 75 of the Consumer Credit Act 1974.8 This gives the patient the option to bring a claim against the credit card company if the supplier, in these circumstances the practitioner/clinic, has breached the contract between itself and the consumer. For example, if the treatment was paid for by credit and if the outcome was not as agreed (e.g. if the procedure did not give the results anticipated), the patient may be able to claim against the credit company. If that claim is accepted, the credit company will then seek to pass the costs on to the supplier, so the practitioner/clinic. This claim

would be to reimburse the patient for the money paid for the services. Although this is not hugely common, it does happen.

Summary In the event that a complication arises, I would suggest that the following steps should be taken immediately to ensure an effective response: 1. Notify the patient 2. Inform your insurers 3. Ensure all documentation is up to date and kept secure 4. Thoroughly investigate the incident It is important to understand the type of claim that may be made against you and your professional and statutory responsibilities. Unfortunately, despite all best efforts and intentions, complications do sometimes occur. It is important that practitioners have appropriate procedures in place to mitigate the risks of those complications occurring, to take action following complications, and to reduce any harm which the patient may have suffered. Emma Galland is a Partner in the healthcare team of Hill Dickinson LLP. She has acted for public and private healthcare bodies for over 15 years. Galland has been involved in a number of high profile inquests and public inquiries, and was instructed by one of the core participants at the Francis Inquiry. REFERENCES 1. General Medical Council, The professional duty of candour, <https://www.gmc-uk.org/ethical-guidance/ethical-guidancefor-doctors/candour---openness-and-honesty-when-things-gowrong/the-professional-duty-of-candour> 2. Care Quality Comission, Regulation 20: Duty of Candour <https://www.cqc.org.uk/guidance-providers/regulationsenforcement/regulation-20-duty-candour> 3. Care Quality Comission, Regulation 20: Duty of Candour, Full Regulation <https://www.cqc.org.uk/guidance-providers/ regulations-enforcement/regulation-20-duty-candour#fullregulation> 4. Legislation act.gov, Criminal Justice Act 1982 < https://www. legislation.gov.uk/ukpga/1982/48/contents> 5. E-law resources.com, Bolam v Friern Hospital Committee [1957] 1 WLR 582 < http://www.e-lawresources.co.uk/Bolam-v--FriernHospital-Management-Committee.php> 6. E-law resources.com, Bolitho v City and Hackney Health Authority [1996] 4 All ER 771 < http://www.e-lawresources.co.uk/ Bolitho-v-City--and--Hackney-Health-Authority.php> 7. Judicial College Guidelines For The Assessment Of General Damages In Personal Injury Cases 14th Edition (September 2017) 8. Which.co.uk, Section 75 of Consumer Credit Act <https://www. which.co.uk/consumer-rights/regulation/section-75-of-theconsumer-credit-act> 9. Thomson Reuters Practical Law, Glossary, Causation <https://uk.practicallaw.thomsonreuters.com/4-1075865?transitionType=Default&contextData=(sc. Default)&firstPage=true&comp=pluk&bhcp=1>

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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“Medical practitioners need to have an understanding and a respect for business” Dr Vishal Madan reflects on his career in dermatology and shares advice on how to make the most of an aesthetic practice He’s a consultant dermatologist, a laser and Mohs micrographic surgeon at Salford Royal NHS Foundation Trust, the president of the British Medical Laser Association (BMLA) and honorary senior lecturer at the University of Manchester and Clinical Director of Everything Skin Clinic, but where did it all begin for Dr Vishal Madan? After obtaining a medical and dermatology degree in India from 1992 to 2001 and working as a senior dermatology registrar in New Delhi, Dr Madan decided to move to the UK in 2002 to take part in new developments that were happening in the West. He explains, “I wanted to see what I read in textbooks transpiring into clinical practice. The field of dermatology, especially lasers, was non-existent in India at the time and I was fascinated by the technology.” However, he was soon faced with the harsh reality that becoming a consultant dermatologist wasn’t as easy on UK soil. Dr Madan says, “I took the PLAB exam (a test which ensures doctors who practice abroad have the right knowledge to practice in the UK) and was very naive in thinking that as soon as I came to the UK I would get a dermatology position. It took me many applications to get my first shortlisting for a house officer position.” Eight years later Dr Madan has undertaken extensive training, which consisted of a year working as a house officer at the Manchester Royal Infirmary, a two-and-a-half-year medical rotation at Addenbrookes, Cambridge University Hospital, membership and later fellowship of the Royal College of Physicians (MRCP, FRCP) and two Fellowships; one in lasers and the other in advanced skin cancer surgery called the Mohs micrographic surgery. “It was a long but enjoyable journey,” he reflects, adding, “I did find that from doing my training in India, I was much ahead of my colleagues as I already had that theoretical knowledge. I was a little older, but age should never be a barrier to gain qualifications.” This passion for learning has prompted Dr Madan to pass his knowledge on, so he

launched a laser training course, for the University of Manchester, and contributes to the laser courses run by the BMLA. “I conduct the laser module and course for MSc in Aesthetic Medicine and the laser course that I run as part of the BMLA is just one of the great things that the organisation does. The BMLA in particular is a unique organisation in that it offers, besides core of knowledge, courses on epilation, vascular, ablative and pigment specific lasers and light based devices. One of my proudest achievements whilst serving as a president of the BMLA, has been the publication of the Essential Standards, which is now used as a benchmark for Health Education England and local councils that inspect laser clinics. The Essential Standards form a framework on which new laser educational courses would be based – these go a long way in fulfilling an unmet need in this area.” he says. When discussing aesthetics specifically, Dr Madan admits that he has debated whether or not a dermatologist has a role within the sector as some believe that they should solely focus on skin conditions and disease. However, he feels strongly that the two work in tandem. He explains, “Aesthetics is not only about science but it’s an art, not everyone can be good at it. Aesthetic practitioners deal with skin every single day and actually, by combining the two, you are making the patient journey smoother. Take acne scarring for example, a patient may go and see their GP, who will refer them onto a consultant dermatologist, who then may refer them onto a laser specialist – combining all of these just makes sense.” Another area that Dr Madan is passionate about is business management. He says that, as aesthetic practitioners, you are running a business as well as offering medical procedures, so being able to switch hats is essential. “So many medical professionals working in the NHS don’t see the business side of things. What I have learnt is that everyone should have some understanding and respect for business, specifically small

What treatment do you enjoy giving the most? I enjoy giving laser treatment for rhinophyma as I think you can get exceptional results. I also enjoy performing Mohs and skin surgery. People are very anxious about skin cancer diagnosis so if you can treat them and offer them a good aesthetic outcome, that’s a great feeling. Do you have an industry pet hate? Free consultations! By doing this I believe practitioners undermine their profession. Free consultations should not be used to entice patients to buy services, that’s unethical. I’ve trained and worked for 25 years and believe that all that I have learned has immense value, so I would not dispense it for free. What aspect of your specialty do you enjoy the most? I love it when I get spontaneous thanks from patients for changing their lives in small ways. I think that’s the most gratifying thing that can happen to any doctor. businesses,” he says, adding that he thinks many practitioners are lacking training or knowledge in this area. “When I first started, my only focus was on the patient. Now as a private business owner, I am aware I need to think of three main things; the patient, the business and the overheads of running a clinic, strictly in that order. The most important thing is never ever compromise on patient safety; you are working for the patient at the end of the day. Even when you have your business hat on, your focus shouldn’t shift,” he says. Dr Madan advises that practitioners should take it slowly and gradually, study their market and always add something extra. He concludes, “Going the extra mile for your patient will set you apart from everyone else. I say to my staff, don’t oversell and don’t push your patient into any procedure.”

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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that you choose to undertake.4 As a nonprescribing aesthetic nurse, you will be taught how to inject POMs, but will need to have a prescriber authorise you to use them. This becomes much more of an issue should a complication arise, from a dermal filler for example, as ultimately you will be relying on a third party to resolve the situation and prescribe hyaluronidase, which consequently results in a poorer service and experience for the patient. In worst case scenarios, it could lead to serious long-term implications. This is one of the many reasons that in my opinion, becoming an independent nurse prescriber in aesthetics is absolutely fundamental and should be integrated into aesthetic nursing training from the get-go.

The patient journey

The Last Word Independent nurse prescriber, clinic owner and honorary BACN board member Frances Turner Traill argues that all aesthetic nurses should hold a prescribing licence According to the British Association Cosmetic Nurses (BACN) there are currently more than 4,000 nurses practising in the aesthetic specialty,1 many of whom will have probably had very different pathways into this private sector. Whether they have been working in the NHS for over a decade, as many of my peers have, or decided early on in their career that they want to specialise in aesthetics, there is always one question that presents itself very quickly and that in my opinion, validates their expertise. Are they an independent prescriber? It is important to recognise that many nurses entering aesthetics will already have a prescribing licence and although technically they will be able to prescribe toxins for example, they should know what is within their remit and recognise their limitations. If they have never worked with products such as these before then I believe they should undertake the significant training required to administer toxin, or to prescribe it for others to administer. For those who have not obtained this qualification, they must undertake a specific course, detailed in this article. In laymanâ&#x20AC;&#x2122;s terms, an independent

nurse prescriber has the authority to administer prescription-only medicines (POMs) such as botulinum toxin or hyaluronidase. To obtain this qualification, known as a V300,2 nurses will need to undertake a prescribing course at an approved university. They will also need to have been practising for a minimum of one year (university dependent) in the area they wish to prescribe in and have a designated medical practitioner (DMP), usually a doctor, working in aesthetics, prior to the course.3 Generally speaking, it will take around six months to complete, with a minimum of 90 hours of prescribingrelated practice under your DMP; all of which is subject to the specific course

For most of us, the reason that we started out in nursing was to provide a service and a duty of care to our patients and making the patient journey as smooth as possible is essential for us to accomplish this. It is from this that I believe that aesthetic nurses who do not hold a prescribing licence are not offering their patients a full service because they simply cannot manage their care throughout the whole patient journey; from the consultation stage through to treatment and reviewing them right until theyâ&#x20AC;&#x2122;re discharged, if there ever really is a discharge in aesthetics, which is a whole other topic in itself. In addition to being able to manage complications should they arise, another point to add to this is that they will also be able to prescribe lidocaine which in turn, will help with patient comfort as it reduces pain for certain injectable procedures.

Career progression So many nurses have successfully opened their own clinic and train delegates on behalf of companies but, in my experience, those of which are non-prescribers are now very few and far between, a significant

It allows you to provide a more streamlined, efficient, effective, safer patient journey

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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Becoming an independent nurse prescriber in aesthetics is absolutely fundamental and should be integrated into aesthetic nursing training from the get-go change from a few years ago. In order to excel in your career, as an individual, holding that extra qualification at a time where it is not compulsory yet will not only set you apart from others in the marketplace who cannot prescribe but it will instil you with confidence. I believe that it gives you a far better understanding of pharmacology of your treatments, which in turn will help your professional development. Working autonomously in aesthetics is very common and, in my opinion, should only be possible for those who hold the prescriber’s licence, unless you work under practising privileges with your prescriber as an interim measure and are working towards your prescribing licence. This is because you will not be relying on someone else to authorise access to products for you, particularly in the case of a complication, and instead will be able to take control of your own actions and ultimately be responsible for resolving the issue that you may have caused.

Opposing views I recognise that not everyone wants to be a nurse prescriber, for example, they may work closely within a clinic environment whereby a prescriber is readily available and that set-up works well for them. Some people would argue that they don’t have to be a prescriber to administer most dermal fillers (although JCCP standards state otherwise),5 so why should they go through all of that time, money and effort? In my opinion, for those who think like this, the likelihood of a complication increases – surely increasing your learning is only going to be a benefit. Regarding our professional regulators, such as the NMC, we want to ensure that we are as safe as possible at all times. We could argue that if we cannot prescribe 24/7 and are working in isolation we are not being

safe. There will be some who do not want the responsibility, in which case I think you should absolutely be working for a clinic that is either registered with Healthcare Improvement Scotland (HIS) or the Care Quality Commission (CQC) so that there is an added safety net for patients to fall back on.6 I also understand that it can be difficult to get onto university prescribing courses and there are stumbling blocks along the way, such as working in the private sector and usually being self-funding. The biggest hurdle is that it can be incredibly hard for people to find a DMP who is willing give their time and supervise you throughout the whole course. They also usually require a fee. This was one of the concerns raised by a number of members at the BACN board meetings. As a result, my colleague, previous BACN vice chair and independent nurse prescriber Andrew Rankin has worked and continues to work with a number of regulatory authorities to address various nurse prescribing concerns. In addition to this potential role of nurses as DMPs, issues of holding stock, prescribing for complications and even the implications for VAT have required his focus. I believe this will make a significant change within the sector.

allows you to provide a more streamlined, efficient, effective, safer patient journey. In the future, I hope to see that prescribing licences are integrated into the training of all nurses, including those who aren’t in aesthetics, from the beginning of their careers. This could mean that we see a decline in complication rates due to prompter action and improvement in regulation within the specialty. Frances Turner Traill is an independent nurse prescriber and owner of FTT Skin Clinics in North and Central Scotland. She was board member of the British Association of Cosmetic Nurses (BACN) for 6 years, now honorary board member and will continue to represent BACN on new regulation changes with Scottish government and Health Improvement Scotland. REFERENCES 1. BACN, The role of nurses in aesthetics <https://www.bacn. org.uk/education/the-role-of-nurses-in-aesthetics/> 2. Nursing and Midwifery Council, Standards of proficiency for nurse and midwife prescribers <https://www.nmc.org. uk/globalassets/sitedocuments/standards/nmc-standardsproficiency-nurse-and-midwife-prescribers.pdf> 3. BACN, Entering aesthetics <https://www.bacn.org.uk/ education/entering-aesthetics/> 4. Harley Academy, Nurse prescribing courses <https://www. harleyacademy.com/nurse-prescribing-courses/> 5. JCCP, JCCP and CPSA Guidance for Practitioners Who Provide Cosmetic Interventions <https://www.jccp.org.uk/ ckfinder/userfiles/files/JCCP%26CPSA%20Code%20of%20 Practice_v2.pdf> 6. CQC, Complain about a service or provider <https://www. cqc.org.uk/contact-us/how-complain/complain-about-serviceor-provider>

Conclusion For me, being able to be, and offer, ‘the whole package’ makes for a better practitioner with greater patient safety at the core. Being able to prescribe potential live-saving medicines, comes with responsibilities, one of which is diagnosing, which is something not everyone does in medical aesthetics. I hope that it can improve complications management across the board. I’m not saying that holding a prescribing license makes you a better injector, of course it doesn’t, but it

Reproduced from Aesthetics | Volume 6/Issue 2 - January 2019


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