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S Y IC R ! ET T N H EN O ST S SO D AE AR ES S AW L O C

VOLUME 7/ISSUE 8 - JULY 2020

Photoageing and Skincare CPD Dr Priya Shah explores the causes and topical treatments for photoaged skin

Innovations in Photoprotection

Mr Paul Banwell details the latest research and evidence in suncare products

Skin and Blue Light

Dr Aileen McPhillips discusses the impact of blue light on skin and how to advise patients

Generation Marketing

Duncan Stockdill recommends how to reach customers of all generations


Contents • July 2020 06 News The latest product and industry news 13 News Special: The Rise of Skincare in Lockdown Recent statistics on the increased interest in personal care 14 Thought Piece: Practising Post COVID-19

Dr Tahera Bhojani-Lynch reflects on her reopening experience

16 Aesthetics Awards Success Stories Gain entry tips from some of last year’s winners 19 Recognising the Impact of Facial Differences Raising funds for Facing the World charity 20 CCR: Your Opportunity for Live Education Reuniting the medical aesthetics community on October 1-2

CLINICAL PRACTICE 22 CPD: Photoageing and Skincare Dr Priya Shah explores the causes and treatments of photoageing 26 Advertorial: Embracing Change with Celluma Reimagine your business model with Celluma Light Therapy 29 Treating Dry and Dehydrated Skin Dr Anjali Mahto discusses skincare physiology and considerations 33 Case Study: Administering a TCA Peel Nurse prescriber Amanda Wilson introduces medium-depth peels 37 Assessing Acne Dr Aneesha Ahmad shares advice on acne assessment 42 Advertorial: Using the BELOTERO Range Dr Paula Mann provides an overview of the BELOTERO dermal filler range 44 Exploring Innovations & Technology in Photoprotection Mr Paul Banwell details the latest research and evidence in suncare 49 Managing Eczema Nurse Emma Coleman shares her holistic approach to treating eczema 52 Advertorial: Discoloration Defense Dr Alexis Granite discusses SkinCeuticals’ Discolouration Defense Serum 55 The Impact of Blue Light on Skin Dr Aileen McPhillips discusses the impact and risks of blue light on skin 60 Exploring CBD as a Skincare Ingredient

Dr David Gleeson and Dr Sandeep Cliff examine the evidence

63 Understanding Laser Plumes Physicist Mike Murphy explores risks associated with plumes 66 Understanding Xanthelasma Dr Firas Al-Niaimi explores the aetiology and treatment options 69 Abstracts A round-up and summary of useful clinical papers

IN PRACTICE 71 Hosting Press Events PR and communications consultant Julia Kendrick provides practical tips for

holding a press event

74 Marketing Across Generations Customer specialist Duncan Stockdill explains multigenerational targeting 77 In The Life Of Dija Ayodele The aesthetician tells us about life outside of lockdown 78 The Last Word Nurse Julie Scott argues why discounting procedures is bad for business

Clinical Contributors Dr Priya Shah graduated in dentistry in 2002 from King’s College London and is the founder of Dr Priya Shah Facial Aesthetics, London. She is currently undertaking study for a MSc in Skin Ageing and Aesthetic Medicine. Dr Anjali Mahto is a cosmetic dermatologist at 55 Harley Street in London. She is the author of The Skincare Bible, as well as a member of the British Cosmetic Dermatology Group and a spokesperson for the British Skin Foundation. Amanda Wilson is a nurse prescriber with a BSc (Hons) in Adult Nursing. She has worked in aesthetics for six years at a number of London clinics. Wilson is one of the lead trainers at Healthxchange Pharmacy. Dr Aneesha Ahmad qualified in 2008 from the University of Manchester. She works as a GP principal with a special interest in dermatology, having completed her Diploma in Practical Dermatology with distinction. Mr Paul Banwell is a consultant plastic surgeon and the director of The Banwell Clinic. He has published more than 100 papers, manuscripts and books, and was the founder and former head of The Melanoma and Skin Cancer Unit (MASCU) in East Grinstead. Emma Coleman is a dermatology and aesthetic nurse practitioner with clinics in London and Kent. She trained in aesthetics in 2015 and gained a distinction in her Clinical Dermatology Diploma with the University of South Wales in 2019. Dr Aileen McPhillips is a medical graduate of Queen’s University, Belfast and currently works as a GP and aesthetic practitioner, running her own clinic ‘Aesthetics by Dr Aileen - The Skin Health Clinic’. Dr David Gleeson is an internal medicine trainee at East Surrey Hospital. He trained at Oxford University before completing foundation training in London. He previously worked as a dermatology clinical teaching Fellow at Imperial College London. Dr Sandeep Cliff is a consultant dermatologist at a university hospital and has a particular interest in skin cancer and inflammatory dermatosis. He has lectured internationally on various non-invasive techniques for facial rejuvenation. Mike Murphy is a physicist and bioengineer with 34 years’ experience in medical lasers. He started Dermalase Ltd in 1989 to launch the QS ruby laser into medical markets in the US, EU and Asia. He has published more than 25 articles, reports and papers. Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon and has written for more than 180 publications. He is a senior research fellow in the dermatology and laser department at Aalborg University.

ENTER BY JULY 31!


Editor’s letter Skincare – an integral part of aesthetic practice. And for many, a key source of income over the past few months while clinics have been closed. Anecdotal reports suggest that online skincare sales have soared throughout Chloé Gronow lockdown. This notion is supported by Editor & Content statistics from L’Oréal that found discussions Manager of skincare ingredients on social media have @chloe_aestheticseditor increased dramatically since last year (for example, retinol mentions are up by 74%), along with survey results that suggest that 45% of consumers are taking more time to care for their skin. It seems that while people have been wearing less makeup and seeing their face more often on video calls, many have become increasingly conscious of the appearance of their skin and want to take action – something I can certainly attest to! As a result, now more than ever seems like the perfect time to enhance your patients’ understanding of how good skincare can help them, while capitalising on your sales! We cover the

statistics from L’Oréal in more detail, with comment on what this could mean for you, on p.13. In fact, this entire issue is dedicated to topical treatments to enhance skin quality. You’ll find pieces on photoageing, eczema, acne, dry skin, pigmentation, xanthelasma, how blue light impacts skin (particularly relevant with increased screentime over lockdown) and, interestingly, an overview of the evidence behind cannabidiol in skincare products. We do hope you find the articles beneficial! Finally, I must remind you that entry to the Aesthetics Awards closes on July 31. And just because you’ve been out of clinic for a few months, it shouldn’t stop you from entering! All the categories ask you to reflect on your previous year in aesthetics, right back to January 2019, so don’t miss your chance to take part. When you’re celebrating your successes at the ceremony in March, I promise you won’t regret it! Sending everyone best wishes as your clinics start to reopen. Do keep us updated with progress and get in touch if you have any words of wisdom for fellow practitioners as you navigate your way through this ‘new normal’!

Clinical Advisory Board

Leading figures from the medical aesthetic community have joined the Aesthetics Advisory Board to help steer the direction of our educational, clinical and business content

WE WANT TO HEAR FROM YOU!

Mr Dalvi Humzah is a consultant plastic, reconstructive and aesthetic surgeon with more than 20 years’ experience and is director of P&D Surgery. He is an international presenter, as well as the medical director and lead tutor of the multi-award-winning Dalvi Humzah Aesthetic Training courses. Mr Humzah is founding member of the Academy of Clinical Educators at the Royal College of Physicians and Surgeons of Glasgow. Mr Dalvi Humzah, Clinical Lead

Do you have any techniques to share, case studies to showcase or knowledge to impart?

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 for 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 nonsurgical medical standards. She is a registered university mentor in cosmetic medicine and has completed the Northumbria University Master’s course in non-surgical cosmetic interventions.

Miss Elizabeth Hawkes is a consultant ophthalmologist and oculoplastic surgeon at the Cadogan Clinic in Chelsea, London. She specialises in cosmetic eyelid surgery and facial aesthetics. Miss Hawkes also leads the emergency eye care service for the Royal Berkshire NHS Foundation Trust.

Jackie Partridge is an aesthetic nurse prescriber with a BSc in Professional Practice (Dermatology). She has recently completed her Master’s 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 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 AntiAgeing Experts. Dr Patel is passionate about standards in aesthetic medicine.

Mr Adrian Richards is a plastic and cosmetic surgeon with 18 years’ experience. He is the clinical director of the aesthetic training provider Cosmetic Courses and surgeon at The Private Clinic. He is also member of the British Association of Plastic and Reconstructive and Aesthetic Surgeons and the British Association of Aesthetic Plastic Surgeons.

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 Stefanie Williams is a dermatologist with special interest in aesthetic medicine. She is the founder and medical director of the multi-award 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.

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© Copyright 2020 Aesthetics. All rights reserved. Aesthetics is published by Aesthetics Media Ltd, which is registered as a limited company in England; No 9887184 ABC accredited publication DISCLAIMER: The editor and the publishers do not necessarily agree with the views expressed by contributors and advertisers nor do they accept responsibility for any errors in the transmission of the subject matter in this publication. In all matters the editor’s decision is final.


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Training

Talk #Aesthetics Follow us on Twitter @aestheticsgroup and Instagram @aestheticsjournaluk

#Complications @sharonbennettskin Honoured to present safe injecting lip techniques for @iapcam with my amazing colleagues @drsophieshotter @medikas.medispa @officialdrtahera @drsarahhart @business_boutique_aesthetics. Lots of really good Q&As throughout too, so thank you if you attended. #BLM @drtijionesho To all my black brothers and sisters in my industry that are feeling tired and feeling triggered and feeling unseen and let down, I hear you I see you and I will speak for you and give you a voice. My DMs are open it’s time for a BIG conversation. #Congress @doctoralexuk Aww, that moment when you ‘visit’ an international conference and bump into your good friend @drroseclub, then move a little closer for a ‘selfie’ at the entrance, then get a little too close and conjoin. Looking forward to a virtual weekend congress thanks to @ibsa_derma and @ha_dermauk. Lots of focus on #Aliaxin fillers, facial volumisation and lips! #Training @rajacquilla Back in the TV studio all week filming exciting brand new content for my @ra.academy #Summit series. Watch this space for case studies and videos! Thanks to my incredible team for a solid shoot. All staff, crew and models are tested for COVID-19 daily to ensure appropriate measures. #Diversity @doctoramiee Following the poll I ran on my stories last week on representation of people of colour in the aesthetics industry, I have taken my poll to the industry itself. Today, @aestheticsjournaluk have shared my poll via email to all of their database. I urge all of my industry colleagues to take part in this 2 minute survey via my #linkinbio as a step towards the very necessary change our industry needs.

Live aesthetic training to resume in July Many aesthetic training companies are planning to resume live clinical training for treatments such as injectables from July 4 with new COVID-19 safety measures in place. Aesthetics spoke to Harley Academy and Cosmetic Courses, which both confirmed that they will be running hands-on training while employing advised safety measures for staff, trainees and patients. Dr Tristan Mehta, CEO of Harley Academy, stated, “In order to keep patients and trainees safe, we will be live-streaming to groups of practitioners on our Level 7 programme observing their injection cases. For hands-on training, we will only be running one-to-one training in individual clinic rooms. We believe this is the only safe way to conduct training in the current climate. And of course, within our academy sites, we will be adhering to the advised social distancing, PPE and hygiene measures.” Director of Cosmetic Courses, consultant plastic surgeon Mr Adrian Richards, commented, “We look forward to reopening our doors on July 4 with our dedicated staff and trainers ready for our return. All staff will be tested for COVID-19, and those who come to our clinics will have to declare they are in a fit and healthy state before arrival, with us also providing temperature checks for all those who enter. Training will take place in small group sessions ensuring social distancing is carried out.” Lasers

Cynosure releases new hair removal and skin revitalisation platform Laser manufacturer Cynosure has launched the next generation of the Elite+ alexandrite-ND:YAG system that aims to allow for faster treatments with higher max energy. The new Elite iQ platform utilises Skintel Melanin Reader technology that measures melanin content in order to offer customised laser hair removal treatments and permanently reduce unwanted hair for all skin types. The device also enables practitioners to treat common skin concerns including facial and leg veins, sun damage, facial wrinkles and razor bumps. Cynosure states that the upgraded workstation offers an enhanced user interface with a new dashboard design and a built-in treatment guide to help determine hair removal test spot settings, dynamic screen lighting to easily view the active wavelength, high treatment versatility with adjustable pulse width, fluence and repetition rate, and the ability to save settings for future use. Todd Tillemans, Cynosure chief executive officer said, “The Elite iQ device meets the growing market demand for hair removal and skin revitalisation solutions for men and women across all skin types.”

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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COVID-19

GMC releases advice on returning to work The General Medical Council (GMC) has provided advice to the Joint Council for Cosmetic Practitioners (JCCP) on returning to work post COVID-19. Regulations currently allow an exemption to closing for dental services, opticians, audiology services, chiropody, chiropractors, osteopaths and other medical or health services, including services relating to mental health. The GMC said, “We expect doctors to use their professional judgment when interpreting what is meant by ‘other medical or health services’, and whether there is a genuine medical or health need for treatment which would permit their business to reopen. The standards we set continue to apply during the pandemic and we expect all doctors to act responsibly and reasonably in response to the circumstances they face.” The GMC also stressed the importance of patient safety, telling the JCCP, “As the primary objective of cosmetic treatment is not medical, it may be considered non-essential treatment. Given the continued progress of the pandemic in the UK, ensuring a safe environment in which to practice, with adequate infection control procedures in place is essential. Should a clinic wish to reopen, doctors need to be confident that they have assessed all risks and can operate safely in accordance with the PHE guidance on social distancing.” Executive chair of the JCCP, Professor David Sines, confirmed that the JCCP supports the GMC’s advice. The full GMC and JCCP statement can be viewed on our website. Skincare

Teoxane launches AHA Cleansing Gel Aesthetic manufacturer Teoxane Laboratories has released a new foaming gel that aims to deeply cleanse the skin as well as add hydration for a more even and radiant complexion. The Teoxane AHA Cleansing Gel combines the brand’s patented Resilient Hyaluronic Acid (RHA) technology with glycolic acid, fruit acids and a brightening complex containing niacinamide, vitamin C and phytic acid. The company states that the gel-based formula works to treat hyperpigmentation, fine lines and wrinkles, as well as reducing pore size. Texoane recommends patients use the product once a day in the morning or evening followed by other products in its cosmeceutical range. Jordan Sheals, deputy country manager for Teoxane UK, said, “Knowing how the skincare, and specifically the facial cleanser market is growing, and realising there was a demand within our range for a rinse-off cleanser, we have developed the AHA Cleansing Gel. With its clever combination of RHA, glycolic acid, fruit acids and a brightening complex this new formulation is the perfect addition to the range so far, allowing Teoxane Cosmeceuticals to now have a comprehensive portfolio for resurfacing skin solutions. The AHA Cleansing Gel is designed to effectively remove dead skin cells, dirt and other impurities such as long-wear make-up, ensuring the skin is perfectly prepared your daily skincare regime and your chosen skincare products can achieve their optimum results.”

Vital Statistics Social conversation mentioning cleansing has increased by 25% during the COVID-19 lockdown period (L’Oréal, 2020)

With 34,410 total monthly searches, rhinoplasty is the most searched for surgical procedure in Europe (money.co.uk, 2020)

The global men’s skincare products market is anticipated to expend at a CAGR of 6.2% to reach US $18.92 billion by 2027 (Grand View Research, 2020)

Botulinum toxin was the top non-surgical procedure in the US in 2019 with 1,712,994 procedures reported by surgeons (The Aesthetic Society, 2020)

YouTube is the digital platform that Gen X (ages 37-55) are most likely to be visiting monthly (GlobalWebIndex Audience Report, 2019)

Over half of both male and female hair restoration patients fall between the ages of 30 to 49 years old, 57.5% and 55.6% respectively (ISHRS survey, 2020)

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Events Diary

1 & 2 October, ExCeL www.ccrlondon.com

12 M & A 1R 3 C MH A R1C2H & 2 01231 |/ L 2 O0 N2 D1 O N AESTHETICSCONFERENCE.COM

Digital

New private clinic booking app launches A new website and app that helps patients search, find and book private clinic appointments has launched called ZoomClinic. The platform lists almost all types of private clinics on a single platform such as doctors, dentists, surgeons, physiotherapists, counsellors, podiatrists, chiropractors, aesthetic clinics and wellbeing clinics, amongst many others. It aims to allow patients to search, find, review and book private clinic appointments quickly and easily. The platform was founded by Dr Sadaf Hussain, who stated, “I launched the ZoomClinic Private Clinic Directory after many years of being a GP. I felt there was no single private clinic directory where I could find the healthcare specialist I needed to refer patients to. ZoomClinic provides a fantastic opportunity to create a free profile page highlighting your training and experience, upload your photos and let the world see who you are. The ZoomClinic platform also provides free appointment booking software that clinicians can manage easily from their phone and clients can view and book into directly.”

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Advisory board

Black Aesthetics Advisory Board forms Four award-winning aesthetic professionals have established the Black Aesthetics Advisory Board (BAAB) in order to investigate the experiences of black practitioners within aesthetics, as well as those of black and minority ethnic patients and consumers. Results from recent research suggests black practitioners are facing higher levels of discrimination and less progression opportunities in the specialty. At the same time, the BAAB notes that black consumers have been found to experience difficulties in accessing practitioners who are confident in treating their aesthetic concerns. Founded by aesthetician Dija Ayodele, Dr Ifeoma Ejikeme, Dr Tijion Esho and Dr Amiee Vyas, the BAAB aims to conduct further research and produce a report that will share guidance to brands and professionals, inform training and improve access to aesthetics for black patients. The BAAB says, “Given the worldwide re-emergency of the Black Lives Matter campaign and the poor experience voiced by black and minority ethnic professionals, as well as consumers, we are shocked at the silence from many quarters of the aesthetic industry. Coupled with our knowledge of BME patient experience, we want to investigate and inform change; from ensuring all practitioners understand the needs of black skin to increased representation of black professionals at all industry levels. Through this, we are also able to positively impact the experience of black patients and professionals within aesthetics.” Supported by Aesthetics Media, surveys will be shared amongst the aesthetics community from July and all are encouraged to take part. Radiofrequency

Cutera launches new fractional RF microneedling device Aesthetic technology manufacturer Cutera has launched the new Secret RF fractional radiofrequency microneedling device. According to the company, Secret RF can deliver targeted heat directly into the deeper layers of skin, with minimal damage to the skin’s surface to revitalise, rebuild, and remodel collagen to improve common skin concerns on the face and body, with little to no downtime. The device uses gold-plated stainless steel microneedles to deliver customised radiofrequency energy into varying levels of the skin, ranging from 0.5-3.5mm. The company states that the Secret RF can treat all skin types and is ideal for improving ageing skin, fine lines, wrinkles, scars and acne scars, photodamage, vascular and pigmentation concerns, and striae. Tim Taylor, UK country manager at Cutera, said, “We are delighted to launch this exciting new development in non-surgical antiageing to the UK market. The Secret RF is a device I believe will transform the way many practitioners approach the common signs of ageing.”

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Digital

Get Harley now facilitating online consultations Digital platform Get Harley is now supporting practitioners to book online consultations for in-clinic treatments such as injectables, body treatments, hormone treatments and more. While originally designed to empower practitioners to sell skincare without holding stock, the technology has been adapted to generate personalised booking links and manage appointments to help clinic owners minimise patient contact time in the post-COVID-19 era, while maintaining revenue. According to the company, Get Harley can now also service patients paying a deposit for future treatments at no extra cost to the practitioner. This can be done after a stand-alone consultation about the treatment, or as an add-on after a skin consultation. Fat and cellulite

Venus Bliss launches with medical CE and FDA approval The newest device from global medical aesthetic company Venus Concept, Venus Bliss, has received medical CE and FDA approval. The treatment is intended for use in non-invasive lipolysis of the abdomen and flanks in individuals with a Body Mass Index (BMI) of 30 or less and is also indicated for use in temporary skin tightening, circumferential reduction, and cellulite reduction. The platform incorporates two technologies in one system. According to the company, the 1064 nm diode laser applicators are used to treat focal fat in the abdomen and flanks through non-invasive lipolysis, resulting in fat reduction. The (MP)2 applicator combines multi-polar radiofrequency and pulsed electro-magnetic fields with the company’s VariPulse technology to complete the treatment, aiming to tighten lax skin and reduce circumference. Sarah Hickey, regional director of Venus Concept UK Ltd, said, “We are excited to introduce our fat reduction solution for the abdomen and flanks. The Venus Bliss is comfortable for patients, provides excellent results, and has little-to-no downtime.” Dermal fillers

IBSA shares new assessment and treatment concept Aesthetic manufacturer IBSA Derma launched a new concept for facial assessment, communication and treatment for millennial patients at its first Virtual Conference on June 12-15 called MYVolution. Around 3,000 delegates from 65 different countries attended the Virtual Conference and learnt about the new concept, as well as the latest injection techniques and product updates. The MYVolution approach was inspired by the Instagram selfie culture of millennials to achieve ‘a better version of themselves’. It does this by focusing on specific facial areas and using small amounts of Aliaxin hyaluronic acid to convert the patients’ 2D image into their real life 3D image. MYVolution App is used to help identify the patient’s facial shape as triangular, round and rectangular so that practitioners can proceed with a tailor-made consultation of the areas to be enhanced and involve patients in the decision-making process.

1 + 2 OCTOBER 2020 | EXCEL LONDON

J O I N US AT CCR The UK’s only multidisciplinary event for surgical and non-surgical aesthetics

AGENDA UPDATE As we all start to adjust to the ‘new normal’ facing the challenges of new safety protocol as well as adapting to a much greater focus on all things ‘online’, the Practice Management conference at CCR will be more important than ever. The agenda will feature social media workshops, PR clinics, best-practice for clinic management, updates on the latest clinic software and technology, safety and regulation updates, media training, and more. There will be a focus on interactive sessions so that you can get the most out of your delegate experience, and you will have opportunities for one-on-one ‘clinics’ with our experts for you to get tailored advice for your individual needs.

SPEAKERS SAY.... “CCR provides a very informative set of lectures regarding non-surgical aesthetics, as well as the ethics and legalities surrounding the business. There are so many lectures to attend it is hard to choose between them! The event made me much more informed regarding my new business venture and gave me much more confidence!” Dr Victoria Drummond-Hay, Oral Surgeon and Facial Aesthetics Practitioner

EXHIBITORS SAY... “We are always very impressed with the amazing organization of CCR. It is one of the biggest conferences our company gets to attend and we are very excited to be part of it this year. CCR covers both clinical and business education and features all areas of the industry. It’s such a great opportunity for delegates to learn about the latest products to help develop their business and build relationships. We are excited to showcase how Pabau CRM can help the industry by offering a great practice management software which helps business owners manage their practice seamlessly. Looking forward to a great conference this year!” Meri Redjepi, Head of Customer Success, Pabau

c c r lo n d o n . c om

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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

HIS CONSULTATION AND APPG REVIEW The BACN has now submitted a response to the Health Improvement Scotland (HIS) Consultation into the Regulation of Cosmetic Procedures. We have affirmed that we do not support a parallel system of regulation for non-medical persons carrying out high risk injectable medical aesthetic treatments. The All Party Parliamentary Group (APPG) has also commenced a review into the education requirements of this sector and the BACN will be giving evidence which will align with our response to HIS. Only a registered healthcare professional can consult, assess, manage and treat patients as appropriate to their needs in this field and only medical and nursing practitioners can manage complications.

MEMBERSHIP AND MEETINGS The BACN is delighted that in the last month renewals and new members numbers have soared. It is a surreal time for us all and it has been good to catch up with our friends and colleagues in regional Zoom meetings. They have proved to be very popular and we will keep these going in the future. Many of our members have been involved in delivering and participating in online teaching webinars both in the UK and globally. Virtual teaching is here to stay and finding new ways to deliver education and services is an area we are also currently focusing on.

BACK TO WORK We are delighted that the BACN Operational Guidelines for Back to Practice During the Covid-19 Pandemic have been widely recognised and referenced with large organisations and government-led bodies. As well as harmonising with other guidance available, they are easy-tofollow for all medical practitioners re-establishing their clinics. The staff at BACN will be coming back to work from July and a huge thanks must go out to the board members and regional leads who have really worked hard over the last quarter to attend to members’ needs. We wish all a smooth and successful transition back to clinic. This column is written and supported by the BACN

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Digital

Glowday secures £3.8 million investment deal Glowday, a marketplace where potential patients can find, review and book medically-qualified practitioners for non-surgical aesthetic treatments, has secured £3.8 million in seed capital with private investment business Horatio Investments. Glowday has now completed the first phase of its development with more than 150 doctors, nurses and dentists partnering with it. The next phase will see the platform launch to consumers, supported by a UK-wide marketing campaign, including TV advertising. Hannah Russell, founder of Glowday, said, “Glowday is a tech-driven business for a booming market which is still very much off-line. This will be more important post COVID-19 where practitioners will need as many aspects of their business as possible to be digitised and automated, to enable them to treat more patients. This investment means we’ll be ready to hit the ground running – clinics have huge waiting lists for when their doors reopen.” Training

Cosmetic Courses launches online mentoring Aesthetic training provider Cosmetic Courses is introducing online mentoring sessions for delegates. The company says it wants to support new practitioners who may have found the COVID-19 break from practice daunting. Delegates will be able to schedule 45 minute calls with one of the Cosmetic Courses trainers, where they can discuss injection techniques, product selection and other clinical aspects, as well as business and marketing advice. Director of Cosmetic Courses, consultant plastic surgeon Mr Adrian Richards, said, “At Cosmetic Courses we pride ourselves on the support we give to our delegates. Due to the current climate this has encouraged us to look at alternative ways to continue to provide the high level of support we have become known for. We are excited to be launching the online injectable mentoring and encourage all those who feel they need a helping hand or guidance in getting back into practice to get in contact with us.” Submental

Onda Smart Handpiece released Laser manufacturer Lynton Lasers has introduced a new handpiece to the Onda body sculpting device for treating the submental area, in partnership with DEKA. According to the company, Coolwaves technology utilises a controlled wavelength on the microwave spectrum of 2.45GHz to target unwanted deposits of subcutaneous fat and skin laxity. The Smart Handpiece allows practitioners to guide the electromagnetic field to the lipocytes in order to destroy fat cells in the submental region, whilst also stimulating cellular metabolic processes and collagen production to tighten the skin. The company states that this smooths, sculpts and tightens the facial and neck tissue. Mario Jukic, product manager at Lynton, said, “ONDA has had a phenomenally successful year in the UK, targeting cellulite, fat reduction and skin laxity better than we ever expected. With the redesigned Smart Handpieces, we can’t wait to see what it can do under the chin too.”

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Lasers

Training

DHAT introduces digital blended learning

BMLA highlights laser and IPL safety risks in COVID-19 guidance

Dalvi Humzah Aesthetic Training (DHAT) is introducing a ‘blended learning’ concept to its range of award-winning courses. According to consultant plastic, aesthetic and reconstructive surgeon Mr Dalvi Humzah, the aim is for all DHAT courses to incorporate digital learning followed by hands-on training. The first course incorporating the new concept will launch at the end of June and is called Core Cannula Knowledge. This aims to teach beginner and intermediate practitioners the background of cannulas, what they need to know for clinical practice, and tips for purchasing. Following the completion of the online course, delegates will then be able to book a hands-on training session. Mr Humzah said, “We are excited to be launching the novel DHAT blended learning concept, starting with Core Cannula Knowledge. This approach will ensure those who want to continue learning during lockdown can, and delegates in the future will be able to gain the important theoretical knowledge to make the most of their hands-on learning with us. We are aiming to incorporate this approach with all of our future DHAT courses.”

The British Medical Laser Association (BMLA) has released a guidance document on the resumption of laser and intense pulsed light (IPL) services post COVID-19 lockdown. The document was authored by BMLA president Dr Vishal Madan for and on behalf of the BMLA and explores risk assessment and risk management of lasers, aerosols and COVID-19, discussing general hygiene, PPE, ventilation, smoke evacuation systems and equipment considerations. Dr Madan stated, “As strategies to relax the COVID-19 lockdown are being discussed and implemented, many laser practitioners will seek to resume their services. This document specifically addresses challenges laser practitioners and clinic managers face while reopening their clinics to offer laser and IPL services; taking into account that the reproduction rate ‘R0 number’ for transmission of COVID-19 is 0.7-1 at the time of issuance of this guidance.”

Skincare

Plumes

Obagi Medical launches three new products Global skincare brand Obagi Medical has released the ELASTIderm Facial Serum, Daily Hydro-Drops and the Professional-C Microdermabrasion Polish + Mask, which is also available in two new skincare kits. According to Obagi Medical, after 10 years of research, the ELASTIderm Facial Serum delivers long-lasting improvement in firmness and crepiness to the face, neck and chest. After eight weeks of use, 100% of 38 study participants said their face looked firmer, while 97% said their skin felt more elastic and resilient, less crepey and reported their skin had ‘bounced back’. The Daily Hydro-Drops serum has been designed to provide smoother, hydrated skin, while reducing the appearance of fine lines and wrinkles over time. A study found that after first use, 91% of 55 users said their skin felt smoother, while 84% said it felt instantly refreshed. Finally, the Professional-C Microdermabrasion Polish + Mask is a two-in-one skin polishing mask, utilising ultra-fine crystals to remove dull outer layers of the skin and infuse new skin with 30% vitamin C l-ascorbic acid. A study found that after one application, 88% of participants described a more luminous glow, while after three weeks 98% reported more youthful-looking skin. Obagi Medical has also released the Vitamin C Care Kit and the Ultimate Antioxidant Kit, which each contain a selection of products to support patients on their skincare journey.

Lynton launches the PlumeSafe Turbo smoke evacuator Equipment manufacturer Lynton Lasers has introduced a portable surgical grade smoke evacuator to the aesthetic market. Used by the NHS, Lynton explains that the product reduces plumes generated during laser treatment which, in some circumstances, can contain viruses. While it is not yet known whether laser plumes can transmit coronavirus, the BMLA has recently stated that high efficiency smoke evacuation systems should be used to reduce plumes generated during laser treatment. The device features 10 adjustable suction settings plus turbo mode, an interactive LCD display and filter tracking technology. According to the company, it can easily be placed on a counter, shelf, floor or other locations convenient to the operative area. Lynton Lasers also stated that while the PlumeSafe Turbo reduces aerosol and plume generated during laser procedures, it should be considered as an adjunct to general hygiene including hand washing, PPE and adequate ventilation systems. In addition, Lynton Lasers Lynton Lasers has also released customer guidance for reopening post COVID-19. The guidance includes equipment considerations, management of energy-based devices, smoke evacuation systems, patient safety, PPE, infection control, a COVID-19 risk assessment template and checklist.

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Learning

Dr Raj Acquilla launches online training Aesthetic practitioner Dr Raj Acquilla has launched Summit Online Aesthetic Training. Summit is a digital learning facility for injectors at all levels and aims to take practitioners on a journey from starting their aesthetic career up to master level. Dr Acquilla said, “After training practitioners around the world and speaking at global events as an international KOL with Allergan, I am delighted to be able to share my teachings through my new online Summit training. My principles are grounded in the promotion of excellence, safety, science, education and not just satisfaction, but delighting my patients with exceptional results through precise facial mapping and beautification. I hope Summit can help fellow practitioners be leaders together.” Skin

Skin analyser and treatment device now available Medical aesthetic company E.S.I Novel, part of Essence Group, has launched its analyser and energy treatment device JÓLI360 to clinics. The JÓLI360 device features two handpieces; a skin analyser that measures skin conditions for hydration, elasticity and sebum, and a treatment handpiece. Following skin analysis, data is transferred onto a JÓLI360 touchscreen tablet, allowing practitioners to provide personalised treatments based on the skin’s condition and individual patient’s needs. The treatment is then performed by the practitioner using the handpiece featuring low level laser therapy, bipolar radiofrequency and electroporation. Dr Haim Amir, CEO and founder of Essence Group said, “Essence Group is driven by its constant desire to innovate, expand the company’s horizons, and reach new markets. The launch of JÓLI360 reflects this commitment to revolutionary technology. This disruptive technology offers cosmeticians, spa owners and clinics with an end-to-end solution that promises to be a game-changer in the aesthetics industry.” Training

Interface Aesthetics launches video-based learning platform Aesthetic training provider Interface Aesthetics has launched a video-based learning resource. According to the company, the resource provides high quality, evidencebased theoretical training to medical practitioners in the safety of their own home. It aims to promote safety and excellence in non-surgical aesthetics by making use of anatomy animations, a case video library and video lectures. Dr James Olding, director of Interface Aesthetics and trainee oral and maxillofacial surgeon, said, “Video tutorials promote engagement in the learning process, especially through the use of anatomical computer animations and injectable case videos. Importantly, we have produced a resource which puts safety and anatomy at the forefront of every assessment and treatment, drawing on expertise from across medicine, surgery and dentistry.”

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News in Brief Cutera to reward COVID-19 helpers Aesthetic technology manufacturer Cutera has launched the ‘Heroes Among Us’ initiative to celebrate aesthetic professionals that have made a positive impact during the COVID-19 global crisis. One honouree will be selected to receive a £5,000 donation to the charity of their choice and will be announced during the Virtual Cutera University Clinical Forum (CUCF) on October 23-25. Contact Cutera to nominate a professional by September 1. SafeAP launches The Safe Aesthetic Practitioner (SafeAP) has been created by aesthetic practitioner and NHS surgical trainee Dr Sieuming Ng and NHS surgical trainee Dr Subha Punji aiming to act as a dual market platform for patients and practitioners. Dr Ng said, “For practitioners, SafeAP markets your services and provides you with an effective patient management tool. For patients, it provides them with a list of qualified practitioners. Our vision for SafeAP is to improve safety, empower patients to make informed choices and to champion practitioners by providing them with the basic tools to run their aesthetic business effectively. The website also serves as an information portal for patients.” COVID-19 won’t deter patients from wanting treatments says survey A survey of 2,352 consumers conducted by practitioner register Save Face suggests that 98% want a non-surgical cosmetic treatment once lockdown restrictions lift, but also deemed safety measures to be essential for them to proceed. Save Face also discovered that 94% of the public want to reduce contact time by having remote consultations and follow-up appointments. Other interesting findings of the survey were that 86% said that thorough screening was essential, and 95% said that it was vital the practitioner is a trained healthcare professional with a thorough understanding of infection control. UK founders sell final Skincity share The UK founders of online cosmeceutical skincare retailer Effortless Skin have relinquished their 25% stake in Skincity. Skincity acquired 75% of Effortless Skin from founders Stephen and Helen Elldred in August 2018 and rebranded to Skincity UK, launching in February 2019. It sells 80 skincare lines including brands such as NeoStrata, SkinMedica, SkinCeuticals and iS Clinical. The departure of the founders marks the final step in the expansion, with Skincity now owning 100% of the UK operation. According to Skincity, sales in the UK continue to grow at record speed, with 2019 sales topping £4 million.

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people to access their practitioner in person for information, and even simply their friends for their experiences and words of advice,” she says. As a result, numerous brands and practitioners have taken to social media to share their expertise, through regular methods such as blogs and social media posts, while also utilising new approaches such as Instagram Live sessions. According to Business Insider, the use of Instagram Live – where Instagram users broadcast live to their followers – increased by 70% in March,2 while, according to a Mintel digital marketing analyst, mentions of it on Instagram and Twitter rocketed by 526% between March 8 and March 15.3 With sometimes thousands of consumers tuning into these broadcasts, as well as accessing information through other channels online, Dr Craythorne highlights that some sources of information on skincare may not be evidence-based and can Aesthetics explores recent statistics on the sometimes lack the depth and personalisation that increased interest in personal care throughout consumers require. She emphasises the importance of practitioners only sharing accurate information the COVID-19 pandemic online and the value of recommending individual Spring 2020 – how will you remember it? While it has of course been consultations to find the best products and treatments for patients. a challenging few months for aesthetic practitioners with clinics closed, “While it’s great that people are starting to realise what ingredients work, the time has allowed many to develop their digital skills with the rise sometimes online education doesn’t go far enough. As practitioners, it’s in webinars and online consultations, as well as learning how best our duty to really ensure we recommend the correct products, with the to utilise blogs and social media to educate patients on the value of correct ingredients, to be used in the correct way,” she explains. skincare throughout lockdown. And, according to recent statistics from personal care company L’Oréal, which manufactures SkinCeuticals Keep the momentum products amongst many others, this will have been worthwhile. Results from the L’Oréal research also indicate that Google searches for hyaluronic acid serum have grown by a whooping 124%, while Time for selfcare research suggests retinol sales have increased by a massive 157% In a survey of 600 consumers in the UK, 45% of participants are across the UK during lockdown.1 In addition, 49% of global consumers taking the time to care for their skin, with one in four women and one said they are willing to trade price for better quality products or safety in two Generation Z and Millennials treating themselves to using face assurances.1 So with a clear rise in consumers taking more time to treatment masks and focusing more on skincare.1 L’Oréal also found care for their skin and learn about good quality, safe products, there that social media conversation mentioning #selfcare has risen by is an opportunity for practitioners to capitalise on skincare sales and 42% since the start of lockdown, while 61% of women are spending better educate patients. Reflecting on the statistics, Dr Craythorne more time online, with 45% purchasing skincare online, compared to encourages practitioners to keep the momentum going with evidence30% pre COVID-19. based education that will support patients, whether that’s online or So why now? Consultant dermatologist Dr Emma Craythorne in clinic. Dr Craythone also highlights the need for practitioners to highlights that with more people staying home, seeing their faces be aware of the changes that may be seen as a result of increased more frequently in mirrors and on video conferencing calls, as well handwashing and mask-use in the post-COVID era. “While wearing as wearing less makeup, it’s no wonder they’re more conscious masks could be good for lips, they do promote conditions such of how their skin looks. “This has also likely been prompted by as acne and perioral dermatitis,” she says, recommending that the unbelievable weather we’ve had, meaning more people have practitioners talk to patients about how best to protect both their had UV exposure which has exacerbated skin conditions such as face and hands. “As we move to the new world, it’s important to have melasma and rosacea,” she adds, highlighting that this is likely to these conversations,” she says, concluding, “It’s incredibly important continue throughout the summer months. that patients are pointed in the right direction to purchase the best products for their skin concerns, so they’re not wasting their time or Online education money, and are given the right advice on how they should be used. Statistics from L’Oréal indicate that online discussion of various Patients trust our opinion, so it really is our duty to ensure we share skincare ingredients have all increased year on year; retinol mentions evidence-based knowledge.” are up by 74% since last year, hyaluronic acid up 69%, conversations REFERENCES about salicylic acid and vitamin C are up 55% each, vitamin E 1. L’Oréal, Skincare in Isolation, Data on File. 2. Paige Leskin, Instagram Live usage jumped 70% last month. A psychologist says it’s because discussions have increased by 32% and SPF mentions have jumped ‘people are not designed to be isolated.’ (Business Insider, 2020) <https://www.businessinsider.com/ 1 by 45%. Dr Craythorne suggests that while education on suitable instagram-live-70-percent-increase-social-distancing-psychologist-explains-2020-4?r=US&IR=T> 3. Liz Flora, Instagram livestreams surge in social distancing era, (Glossy, 2020) <https://www.glossy.co/ skincare has been growing online for some time, it has been pushed beauty/instagram-livestreams-surge-in-social-distancing-era> forward as a result of lockdown. “It has of course been difficult for

News Special: The Rise of Skincare in Lockdown

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Practising Post COVID-19 After reopening her practice in May, Dr Tahera Bhojani-Lynch reflects on her experiences of going back to work Lockdown was something my clinic had planned for and we had anticipated some aspects of it from February. In the days running up to the closure, staff were given laptops and were allocated work to do from home when the time came. However, when it happened, it was sudden; we thought we would have two more days, and I had not then realised that staff on the furlough scheme would not be allowed to work at all! Luckily, the laptops came in useful for lots of online training, which was allowed, and we became experts in online shopping and communications. I discovered, with some embarrassment, that Zoom was not the multicoloured ice lolly of my childhood, but the go-to online webinar and video call software! While my staff enjoyed two months of paid leave, spent quality time with their young children, ran errands for elderly relatives and relaxed in the garden through one of the warmest Aprils on record, I spent 10 to 12 hours every day in my home office, in online meetings and on webinars, working and planning our return to work. These are the realities of working for yourself.

Early lockdown To begin with, the days and nights of lockdown rolled into one another. I lost track of time except when punctuated with daily briefings from 10 Downing Street. All my clinic and office staff were furloughed, including my bookkeeper, so suddenly I was managing my own payroll, familiarising myself with the Gov.uk website, the Public Health England

guidelines, and learning all about HMRCâ&#x20AC;&#x2122;s job retention scheme, local government rate rebates, bounce back loans from the bank, and much more. I learnt and I shared; by word of mouth, suddenly I had a small group of businesses (grocer, restaurant, optician, clothes shop) that I was helping to access financial help, teaching them how to run their own payroll and helping with online furlough claims. I prepared live international training webinars for Teoxane, Sinclair and the International Association for Prevention of Complications in Aesthetic Medicine (IAPCAM). I attended faculty meetings online, I volunteered for the Birmingham Nightingale Hospital, studied immunology and virology and felt like I became a COVID-19 expert (didnâ&#x20AC;&#x2122;t we all)! By the end of April we realised that the Nightingale was not going be needed, and the clinic became the priority again. I knew when the time came we would need PPE, infection control measures, distancing and physical barriers in place before safe clinical work could be resumed, but in the early days of lockdown, PPE was almost impossible to obtain, even for essential services like care homes. Consequently, I knew that it would be some time before we were able to put the logistics in place for a safe return to work.

Preparing to return On April 8, the lockdown on China was lifted1 and the international supply chain of PPE reopened allowing us to purchase gloves,

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masks and aprons for ourselves and for donation to essential services. By doing this we were able to start planning a return to work in May. I had always believed that as a Care Quality Commission (CQC)-registered medical clinic, and that as a doctor registered with the General Medical Council, we did not fall under the bracket of businesses that required to close and therefore did not need permission to reopen. I firmly believed that if we assessed and mitigated the risks, we ought to be free to work; if shops selling DIY items were safe to open, how can a doctor treating migraine, acne, scarring, removing moles, offering laser hair removal for NHS patients undergoing gender reassignment, signposting to GPs and mental health counselling, as well as cosmetic procedures, be unsafe? I felt that we did enough noncosmetic work to justify opening even for our cosmetic work. Upon contacting my insurance provider, they were supportive of me reopening. Overheads needed to be as low as possible during the period of zero income, which was to be followed by low income due to restricted numbers of patients when we returned. I arranged for one member of staff to return each week, in staggered rotation, to make the most of the furlough scheme. Each member of staff was asked to come off furlough for one week of work, followed by three weeks back on furlough, and rotate this on a four-week cycle, planning it until the end of July. By mid-May I had written my policies,2 filled a treatment room with PPE and disinfectants, and re-trained my staff. It took a full four weeks to prepare properly, which included physical changes to the clinic, incorporating screens for the reception area to protect retail staff, and diary changes to keep appointments spaced. We had a staff practise day to train in the COVID-19 specific procedures, including how to don and doff PPE, having antibody tests, how to implement cleaning, infection control measures and social distancing for patients and colleagues alike. We mimicked patients coming in, measured 2m distances, worked out how we would take card payments with screens in place and decided how many staff we could have and keep a 2m distance between people.

The challenges of reopening clinic The clinic reopened on Thursday May 14 with telephone consultations and we began seeing patients face-to-face from Monday May 18. It was timely that the British College of Aesthetic Medicine (BCAM) issued its formal

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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As a business owner, I am grateful to have been able to reopen and be earning a living, but as a healthcare practitioner, I cannot help feeling some apprehension of the likely second wave as the summer ends

guidance and legal opinion on members returning, on the same day we reopened.3 I was pleased to see that the College had concluded, as I had, that we were not to align ourselves with beauty salons or hairdressers and that the question was not when we should return, but more importantly, how we should return (i.e. once measures were in place for patient and staff safety and wellbeing in line with government guidelines). We had scarcely been seeing patients for a week when we had an unannounced visit from the local council environmental health officer. She arrived outside the clinic in response to a written complaint made by an ‘allied professional’ with ‘a genuine concern for public safety’. I suspect this complaint came from a nurse working out of a local beauty salon. The officer insisted on speaking to me immediately, even though I was in the middle of a treatment. I had to step outside in full PPE while I was questioned rigorously on who had given me permission to open, what kind of patients I was seeing, whether they were cosmetic or medical, whether I had sufficient PPE onsite, how often I was changing PPE between patients (sessional use or single use) and what policies and risk assessments I had in place. I was very polite and very co-operative, and was able to say with confidence that I had all the relevant policies and procedure documentation, supported by a comprehensive risk assessment, ready for inspection if required.2 In addition, I had a guidance document from BCAM supporting my return.3 I was asked to submit my evidence to the council by email by the end of the day, but she agreed that

I could continue to work until a decision had been made. I was grateful to be able to add BCAM’s legal opinion amongst the documents I submitted to the council for their perusal. I was advised by phone the following morning that, having reviewed the documents, the council were happy that I was not in breach of Government guidelines and I was able to continue to work. They made specific reference to the comprehensive nature of the BCAM document and its legal position. At that moment, I was very grateful for my BCAM membership. Whilst not everybody agreed with the fact that the association had sought this legal opinion, I felt they had acted very much in the interests of their medical and dental members, and for me it had proved to be invaluable. Since then, the daily challenges of the return to work have been tough. I can only see half as many patients a day as I used to; there is only one room in use instead of two to comply with distancing in the clinic, we don’t serve coffee and can’t allow patients to use the toilets. With only one other member of support staff on site, we both clean constantly: rooms, surfaces, hands. We change our own PPE after each patient, we call patients to conduct consultations and to make payments; we document, we file, we and run errands. Cash payments cannot be taken, and the mountains of clinical waste now generated take up space and cost more than ever to be collected. We supplement our traditional clinical income with COVID-19 antibody tests, which we have made compulsory for all patients on arrival. The Rapid tests take

10 minutes to show IgM and IgG status and patients are delighted and keen to find out if they might have had the virus, especially if they have had colds or coughs in the last few months.4 We charge patients £25 to come into clinic now to cover the cost of PPE and the antibody test, which patients have thought is very reasonable under the circumstances.

Looking to the future In spite of the UK having one of the highest reported COVID-19 death rate per head of population anywhere in the world,5 the beautiful weather and current drop in the rate of transmission of the virus has made us hopeful for the future. As a business owner, I am grateful to have been able to reopen and be earning a living, but as a healthcare practitioner, I cannot help feeling some apprehension of the likely second wave as the summer ends. But for now, we are making hay while the sun shines! We don’t know how long we have before we may need a second lockdown, so we are busy working and earning, sharing our knowledge and experiences with colleagues. I am happy to share my clinic’s written policies and procedures on request via email2 and have colleagues who can supply 3ply medical grade 1 masks and antibody tests etc via the www.Kapoff.co.uk website.6 As practitioners, we will definitely be more successful if we support each other; we really are better if we are all in this together. Dr Tahera Bhojani-Lynch is an international awardwinning doctor and laser eye surgeon specialising in ophthalmology and aesthetic medicine. As a member of the Royal College of Ophthalmologists, she was the first female British graduate to perform LASIK eye surgery in the UK. Qual: MBChB, MRCOphth, CertLRS, MBCAM, DipCS, BTech (Laser Skin) REFERENCES 1. Nectar Gan, China lifts 76-day lockdown on Wuhan as city reemerges from coronavirus crisis, CNN, April 8. <https://edition. cnn.com/2020/04/07/asia/coronavirus-wuhan-lockdown-liftedintl-hnk/index.html> 2. Dr Tahera Bhojani-Lynch COVID-19 clinic policy, available upon request <officialdrtahera@gmail.com> 3. BCAM releases return-to-clinic advice for members, May 15, 2020. <https://aestheticsjournal.com/news/bcam-releasesreturn-to-clinic-advice-for-members> 4. Gov.uk, For patients, the public and professional users: a guide to COVID-19 tests and testing kits, 2020. <https://www. gov.uk/government/publications/how-tests-and-testing-kitsfor-coronavirus-covid-19-work/for-patients-the-public-andprofessional-users-a-guide-to-covid-19-tests-and-testing-kits> 5. WHO Coronavirus Disease, World Health Organization, 2020. <https://covid19.who.int/> 6. Kapoff <www.kapoff.co.uk>

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


Aesthetics Awards Special Focus

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Entering the Aesthetics Awards Not sure whether to enter the Aesthetics Awards? Lacking confidence in writing a strong entry? Read on to learn about the experiences of our previous winners and their top tips…

JACKIE PARTRIDGE

JULIA KENDRICK

WINNER OF THE SPRINGPHARM AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR

JOINT WINNER OF BEST CLINIC SUPPORT PARTNER

MARY WHITE (OUTLINE CLINIC),

TEOXANE UK, WINNER OF THE DALVI HUMZAH AESTHETIC TRAINING AWARD FOR BEST SUPPLIER TRAINING PROVIDER

WINNER OF THE CCR AWARD FOR BEST CLINIC MIDLANDS & WALES

ALISON TELFER (THE GLASSHOUSE CLINIC),

KELLY TOBIN WINNER OF THE HEALTHXCHANGE AWARD FOR SALES REPRESENTATIVE OF THE YEAR

WINNER OF CLINIC RECEPTION TEAM OF THE YEAR

DR EMMA RAVICHANDRAN AND DR SIMON RAVICHANDRAN (CLINETIX) WINNERS OF THECANDELA AWARD FOR BEST CLINIC GROUP, UK & IRELAND (3 CLINICS OR MORE)

DR SOPHIE SHOTTER (ILLUMINATE SKIN CLINIC), WINNER OF THE PROFHILO AWARD FOR BEST CLINIC SOUTH ENGLAND

WHY DID YOU DECIDE TO ENTER THE AESTHETICS AWARDS?

JACKIE PARTRIDGE: I have entered the Awards for the last five years as it’s seen as the crowning achievement within our industry. I’ve been either Highly Commended or Commended for Best Aesthetic Nurse Practitioner each year until 2019 when I won! Yippee!!!

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JULIA KENDRICK: It’s the gold standard for our industry and a great way to showcase your work for current and prospective clients. MARY WHITE: We enter the Awards for several reasons, but for the main part it is for recognition of our staffs’ tremendous efforts in supporting a safe and top-rate clinic all year round. It is also helpful for Aesthetics | July 2020

our patients when they are choosing a practitioner, as it directs them to a clinic of excellence. TEOXANE UK: The Aesthetics Awards are an important date in the aesthetic industry calendar, of which we love to be involved. We entered the Awards in three categories that we felt were a great fit for us and to showcase how incredibly hard our team works.


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HOW HAS WINNING BENEFITED YOU IN THE PAST YEAR?

CAN YOU SHARE ANY ENTRY TIPS?

MARY WHITE: Tips include being succinct and answering the question! I have read entries that sound wonderful and they are clearly a clinic of excellence, but they haven’t answered the question in point! Make sure you read the question, answer the question and give evidence for your answer. Make your answers measurable and appropriate. Use bullet points where you can. KELLY TOBIN: I enjoyed looking back over the years and pulling out personal achievements to add to my entry. My top tips are to be honest and give examples where possible! TEOXANE UK: The Aesthetics Awards panel are looking for a comprehensive, honest and scientific entry. Our advice would be to be sure to include all the data that makes your product or service stand out – your authentic point of difference is what will ensure the judges understand your brand the way you would like them to. Be honest with your entry! Ask for customer/colleagues opinions to help write your entry statements and answers so that you know you are answering from real life experience. ALISON TELFER: The entry process is really straightforward, my advice is to start it early and allow a trusted friend or colleague to have a look at it. Even better if you can get a previous winner to cast their eye over it. Life very often gets in the way, so don’t leave it to the last minute, and don’t be shy – this is the time to shout from the rooftops about all the good stuff you do!

Aesthetics Awards Special Focus

JULIA KENDRICK: We have had several new clients approach us on the back of our award-winning status – it just gives that extra level of prestige and kudos to the business. DR SOPHIE SHOTTER: It’s led to increased engagement on every front – patients had seen social media posts and newsletters about it and congratulated us, and we got some brilliant local press coverage off the back of the award too. More than anything, I think the award lends another tier of credibility – when prospective patients see you’ve won an award like this, it makes a difference to their decision making process when choosing a clinic. JACKIE PARTRIDGE: Apart from the huge sense of personal achievement, it has provided recognition for my existing patients that they had chosen the right person as their injector and given reassurance to prospective patients too. DR EMMA RAVICHANDRAN AND DR SIMON RAVICHANDRAN: Winning at the Aesthetics Awards has definitely given professional credibility to our clinic. The process of entering the awards engaged our patients and enhanced their relationship with the clinic and staff. Staff moral and team work has significantly increased. As the directors, we have incredible pride in the success of all the team.

DR EMMA RAVICHANDRAN AND DR SIMON RAVICHANDRAN: The entry process was clear and straightforward. The questions asked were relevant and gave us the opportunity to showcase the best of our clinic with structure and direction. Our top tips: • Involve your staff in brainstorming content for each answer • Collect written or video testimonials from patients and colleagues who will support your entry • Read each question several times, taking time to reflect on how you can answer concisely. Provide relevant and accurate information which you can support

Aesthetics | July 2020

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Aesthetics Awards Special Focus

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TELL US ABOUT THE EVENING! HOW DID YOU FIND IT?

WHICH C AT EG ORI E S WIL L YOU EN T E R? R E S U LT S • Best Non-Surgical Result • Best Surgical Result

I N I T I AT I V E S • Professional Initiative of the Year

PR ACT I T I O N E R S • Rising Star of the Year • The SpringPharm Award for Aesthetic Nurse Practitioner of the Year • Medical Aesthetic Practitioner of the Year • Consultant Surgeon of the Year

CL I N I C S • • • • • • • •

Best New Clinic, UK and Ireland Best Clinic London Best Clinic South England Best Clinic North England Best Clinic Midlands & Wales Best Clinic Scotland Best Clinic Ireland Clinic Reception Team of the Year

PRO D U C T S • The DigitRx Award for Product Innovation of the Year • Injectable Product of the Year • Energy Device of the Year • Topical Skin Product/Range of the Year • Surgical Product of the Year

CO M PA N I E S • Sales Representative of the Year • Product/Pharmacy Distributor of the Year • Manufacturer of the Year • Clinic Support Partner/Product of the Year

TRAINING

ALISON TELFER: It was great fun and a real team-bonding experience, from the girls all getting ready together, myself having to walk though Mayfair with curlers in my hair... to celebrating our appearance on stage to dancing late into the night. It is always a real joy to bump into colleagues and chatter of a few drinks. The atmosphere is always great, along with the ladies frocks!!! MARY WHITE: The evening is great fun. It’s extremely well organised and provides a terrific opportunity to network with colleagues and friends in the industry. The entertainment is always good quality and we always enjoy! DR EMMA RAVICHANDRAN AND DR SIMON RAVICHANDRAN: We took all our team to the Awards last year. The celebrations and excitement started at the airport at 7am! It was a real bonding experience, where we shared and recognised the exceptional achievements of everyone’s hard work over the year. The event was exceptional. On the evening, we all felt like celebrities at a global awards event!

WHAT’S THE ONE PIECE OF ADVICE YOU’D GIVE TO SOMEONE CONSIDERING ENTERING? DR SOPHIE SHOTTER: Just do it! You won’t regret it. The competition is stiff, but to even be in the running is a wonderful experience. And if you don’t win this year, you’ll have learnt lessons from it and you will be in a better position to enter again the following year. Honestly, just go for it! ALISON TELFER: Enter, you have nothing to lose and everything to gain, it not only gives you recognition by your peers, the application process really makes you understand what you do brilliantly and what can be worked on, which in turn gives clarity. And, at the end of the day, if you don’t enter, you won’t win, or even be shortlisted! Good luck! JACKIE PARTRIDGE: Just do it! You’ll never know if you don’t try. Consider your entry carefully and take time to review it. Life and work always gets in the way, so start your entry early to give you the time to invest in it. KELLY TOBIN: If like me you were nervous about entering and putting yourself out there – just go for it!

• Independent Training Provider of the Year • Supplier Training Provider of the Year

E N T E R BY JU LY 31 18

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Charity Facing the World

greatly impact their families too. Facing the World notes that with a lack of education in Vietnam around how and why the deformities occur, families are often blamed and shunned by their community.1 In a study published in the Journal of Paediatric Psychology, researchers explain that individuals with visible differences are likely to experience stigmatising behaviours such as staring, avoiding, teasing and manifestations of pity. They also say that the severity of a condition is not a reliable predictor of psychological distress, meaning even those with slight facial differences can be affected.2 After conducting a literature review of available information on the subject, as well as leading their own research for the study, titled ‘Stigmatisation Predicts Psychological Adjustment and Quality of Life in Children and Adolescents with a Facial Difference’, the authors summarise that individuals with a facial difference could Raising funds for Facing the World charity conclude that they are ‘deficient relative to their peers, which can lead to negative self-images and subsequent After describing the harrowing physical differences children can psychological difficulties’.2 As a result of this, they say that live with in our June issue, we spend this month focusing on the affected individuals could react with avoidance of potentially psychological trauma of these children and their families. painful social encounters, which again, may constrain their According to Facing the World, many children suffer from severe mental health issues as a result of their condition. The charity claims that most are unable to attend school or become productive members of society.1 And not only do the children’s facial differences affect them, they

Recognising the Impact of Facial Differences

Medical care should be accompanied by psychological assistance

psychosocial development. Teasing and poor peer acceptance may contribute to emotional problems, such as an increased sense of loneliness and social isolation.2 And while corrective surgery will of course be of benefit, complete resolution is not always obtainable. The authors therefore advise that medical care should be accompanied by psychological assistance.2 A combination of cognitive behavioural therapy and social skills training, with inclusion of the parents is advised, which Facing the World is able to offer with your kind donations.

Lâm’s story Adapted from the original story published in Vietnam News Born with a cleft palate and other facial differences, 12-yearold Lâm is totally deaf in one ear, while the other is impaired. As a result, his father Nguyễn Văn Khảng explains that Lâm has trouble studying and is in a class for nine year olds. He says, “Lâm studies in the same class as his younger brother so that he can help him learn and socialise. Actually he does not really have friends. He wants to socialise but his face is different so his classmates kept making fun of him, staring and pointing at him. He once told me he wanted to grow up like a normal person and not be made fun of.” Lâm is on the waiting list for treatment and will need multiple surgeries as he grows up with no guarantee of results. Lucky to have such a supportive family, his father says, “I really hope that he can finally live a normal life.”

Your contribution can improve education and ensure children are treated fairly.

To donate to this special charity scan the QR Code or visit www.justgiving.com/fundraising/aestheticsmedia

REFERENCES 1. Katrin Kandel, Vietnam Training Program, Facing the World <https://facingtheworld.net> 2. Masnari et al., ‘Stigmatisation Predicts Psychological Adjustment and Quality of Life in Children and Adolescents with a Facial Difference’, Journal of Pediatric Psychology (2013) <https://academic.oup. com/jpepsy/article/38/2/162/948065> 3. Vietnam News, Making sure children face a better future <https://vietnamnews.vn/sunday/ features/569211/making-sure-children-face-a-better-future.html#vFJ7osmMhqECglj8.97>

Aesthetics | July 2020

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1 + 2 OCTOBER 2020 | EXCEL LONDON

Counting Down to the Largest Multi-Disciplinary Show in UK Aesthetics… With the steady advancement of returning to normality, we are all eagerly anticipating the aesthetic market opening for business once again. During this time, we praise the efforts of all involved in making our industry even safer by proactively taking the level of patient care at every clinic, practice and surgery up a notch. The COVID-19 pandemic has had one positive effect on the industry perhaps, forcing all to be even more conscious and sensitive to patient safety and the patient journey. In addition to new safety guidelines, many of our CCR friends and colleagues in aesthetics will currently be focusing on refreshed and revised marketing and PR campaigns to maximise footfall and patient bookings in the wake of the forced closures. This is the best time to plan ahead and start communicating and reconnecting with your audience and customer base once again. Our dedicated CCR PR team at Mantelpiece PR has provided some top tips for getting back on top of your game: • Get In Touch: communicate your new safety measures and protocols to your database with a carefully worded email or text to allay any reluctance to book in for treatment. • Be Patient: don’t expect a miraculous income recovery immediately upon re-opening, be patient and keep safety as your top priority to ensure health issues don’t trip you up in the future – and that goes for the safety of your team and your patients. • Price Consideration: plan your promotional topics for the remainder of the year. What compelling stories do you have to tell, and what truly great products and treatments do have you to offer? Be prepared to offer incentivised pricing, but do not devalue your credibility with too many discounts or too large a discount for patients. Your brand must survive to live another day and too many two for ones will certainly impact your credibility in the medium to long term. • Brand Visibility: Diarise those all-important expos, conferences and events and safely take part where you can. Visibility amongst your customers and peers is key. Utilise your promotional budget carefully on those activities, expos and events that either offer you transactional sales opportunities or an audience with your target market directly. Focus on one or two, such as CCR and ACE, that will work for you during the remainder of this year and put your all into them, utilising all promotional opportunities made available to you.

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Industry commitment to visitor safety

NEW for CCR 2020

This year, CCR is excited to be the first industry expo to confirm its dates, incorporating new social distancing measures to help prioritise exhibitor and delegate safety upon attendance.

• NEW venue: ExCeL London with excellent UK-wide transport links and extensive facilities • NEW CPD-accredited training courses including a one-day video cadaver course with Dr Tapan Patel • NEW Aesthetics Press Conference providing a briefing opportunity for key journalists hosted by Tatler magazine’s Francesca White • NEW educational streams provided by leading brands • Unprecedented number of new product launches due to previous delays throughout the year

Allocated registration times

A one way system around the ExCeL halls

Sanitary measures including masks and hand sanitiser on entry and within the exhibition halls

Clear social distancing measures

Leading Press Coverage at CCR! It is with great pleasure that the CCR team has appointed Francesca White, Tatler Editor at Large and Editor of the Tatler Beauty and Cosmetic Surgery Guide for the second year running as the show’s Press Ambassador. She said, “I am thrilled to have been invited to be this year’s CCR press ambassador once

again. It is such an honour to be involved in THE show for both the surgical and non-surgical disciplines – as well as to be working alongside some of the most eminent practitioners in their fields. The new press conference that I will be chairing is an exciting development, giving press unprecedented access to cutting-edge launches and advancements in aesthetics. I expect it to be a hot ticket for 2020 and the years ahead.”

Register for your free delegate pass and find out more on the CCR website www.CCRLondon.com

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020

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Photoageing and Skincare Dr Priya Shah explores the causes of photoageing and topical treatments for photoaged skin Photoageing is the effect of sun exposure superimposed upon intrinsic ageing, yielding histological, clinical and functional changes that may affect life quality, cause disease and mortality.1-3 Intrinsically aged skin presents in old age as pale, dry, less elastic, with fine wrinkles and exaggerated dynamic lines. This article examines the literature to help aesthetic practitioners in developing an understanding of typical solutions for patients with photoaged skin.

Sun exposure and photoageing Chronic sun exposure causes 80% of facial skin ageing and affects habitually exposed areas including the face, neck, chest, dorsum of the hands, and forearms.4,5 Photoaged skin may present from the late teens with deep wrinkles, rough texture, dryness, dyschromia (freckling and lentigines), sallowness, actinic keratoses, telangiectasias, solar comedones, elastosis, sebaceous hyperplasia and an increased cutaneous neoplasm risk.6-8 Photoageing severity is proportional to accumulated sun exposure, varying on the same individual and is inversely related to pigmentation with fairer skin more significantly affected. Coloured skin shows photoageing up to 20 years later compared to Caucasian skin, where pigmentation changes are commonly noted before wrinkles appear.9 The epidermis shows atrophy when it is photodamaged.10 Dermal changes involve differential remodelling of collagen, elastic fibres and glycosaminoglycans (GAGs), clinically presenting as wrinkling and elasticity loss. Oxytalan fibres rich in fibrillin-1 degenerate at the dermoepidermal junction (DEJ) even in minimally photoaged skin.11 Abundant dystrophic elastotic material, termed â&#x20AC;&#x2DC;solar elastosisâ&#x20AC;&#x2122;, is deposited in the reticular dermis and associated with accumulation of disorganised GAGs. An increase in interfibrillar areas occurs.12-15 Dermal collagen I and III loss also occurs and a reduction in collagen VII anchoring fibrils beneath the DEJ is observed.16-18 When ultraviolet B (UVB) light, which is within the 290-320 nm

range, reaches the basal epidermis it causes acute sunburn; however, multiple exposures in youth behave like chronic exposure in later years.19-21 UVA (320-400 nm) penetrates through clouds and glass, significantly contributing to photodamage. Unprotected sun exposure also leads to primary dermatoporosis.22 Recent studies demonstrate infrared A (IRA), which is between 770-1400 nm, creates dermal changes similar to visible light (VL), which is between 400-700 nm.23,24 Although not well researched, this causes pigmentation changes in darker-skinned individuals.25 A possible theory of why darker skins are more affected could be that they have increased melanogenic activity compared to lighter skin types. The type of melanin produced, the number and packaging of melansomes and varying content of melanin (17.9% in Caucasian skin vs 72.3% in African American skin) plays a significant role in deciding skin colour.26,27,28 Chung et al. (2001) demonstrated that IR and VL increase skin temperature, causing thermal ageing.29 Chen et al. (1994) suggested that cutaneous heat exposure leads to similar histological changes as seen with chronic UV exposure.12 Hence scope exists for further research and development as we know more solar wavelengths are involved in photoageing other than UVR (Figure 1).30 Dermal photoageing induced by UVR exposure occurs by: 1) Increased matrix-metalloproteinase (MMP) driven degradation31 2) Reactive oxygen species (ROS) induction potentially activate MMPs causing telomere shortening32,33 3) Direct protein degradation of UVR-absorbing chromophores like fibrillin-1 and fibulin-5 in the papillary dermis34,35 4) Increased mutation of the mitochondrial genome36 Molecular solar radiation shielding mechanisms degenerate with age, influencing susceptibility and involve the stratified epithelium, which is composed of differentiated keratinocytes and lipids, antioxidant defence and skin pigmentation.23,37

Patient assessment Content in Sunlight

5%

50%

45%

Photoageing ROS/RNS generation DNA oxidation

Heat

Sunburn DNA damage Immune suppression

Blocked by atmosphere

UVC 200

UVB 280

295

UVA2 315

Oxidative damage to DNA and other molecules

UVA1 340

Visible Light 700

Infrared light

700(nm)

Figure 1: The solar radiation spectrum and its effects on skin. Reactive nitrogen species (RNS) acts together with reactive oxygen species (ROS) to damage cells.30

1(mm)

Photoageing presentations that concern patients mainly include wrinkles and pigmentary changes. A full consultation should consider patient and familial medical history, hormonal/menopausal considerations,38 current skincare regime including beauty products and devices used, non-surgical/ surgical treatment history and results as perceived by the patient, skin type (oily/dry), Fitzpatrick type and the degree of photoageing. Their lifestyle should also be considered to identify extrinsic factors, minimising further ageing and creating optimal skin rejuvenation conditions. These

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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may involve photoprotection, avoidance of cigarette smoke and pollution, a diet rich in fruits and vegetables and low in sugary foods, alcohol avoidance, good sleep, exercising, staying hydrated, using antioxidant supplements and topical antioxidant formulations.39 Facial and skin ageing analysis and imaging techniques communicating physical treatment limitations and monitoring patient progress are also useful. Standardised photography demonstrates facial line depths statically and dynamically. Standardised photography-based computerised skin analysis systems provide patient scores comparing surface parameters to others of a similar age. They can motivate patients to improve their habits and allow modifications in their regime.40 Some such imaging systems that are available include PRIMOS, DermaTOP, VISIA, and Antera 3D.41 With no established consensus for evaluating photodamage, some grading systems used include: • The Glogau classification: scores the degree of epidermal and dermal degenerative effects. Category I is treatable with topical treatments and light chemical peels. Category II, III and IV would entail medium to deep peels, lasers or cosmetic surgery. The scale does not predict skin response to topical treatments.42 • The Griffiths scale: uses five high-quality paired photographic standards to which photoaged facial skin is graded against. It has good consistency between assessors and repeatability.43 Fitzpatrick skin type classification: This scale helps predict potential effects of certain treatments according to skin type.44 Severe wrinkles and pigmentary manifestations serve as markers for skin cancer which should be screened for.40 As with all treatments, screening should also be conducted for ‘red flag’ patients as they may have unrealistic expectations, be reluctant to listen to practitioner advice or may have may have body dysmorphic disorder, among other potential issues.45-50

Topical approaches Practitioners would likely need to explain the differences between over-the-counter (OTC), cosmetic formulations termed ‘cosmeceuticals’ and pharmaceuticals. OTC products are nonprescribed but contain active ingredients that elicit structural

Molecular mechanisms

• • •

Increased collagen synthesis: • Inhibition of the UV-induced c-Jun • Alteration in the TGF--β expression Inhibition of collagen degradation: • AP-1-mediated MMP inhibition

• • • •

• • •

• •

Initiation of increased epidermal proliferation EGF-receptor activation via specific induction of its ligands heparin-binding EGF and amphiregulin Increased epidermal differentiation Stimulated transglutaminase, involucrin and filaggrin expression

Inhibition of tyrosinase activity Inhibition of melanosome transfer Physico-chemical UV-photoabsorption

• • • •

• • •

and functional changes. They are endorsed by experts involved in product testing but unlike pharmaceuticals have no proven pharmacokinetics, safety and efficacy profiles having not been rigorously tested, as in placebo-controlled studies.51 Hyperpigmentation-reducing ingredients will not be a large focus for this article but include hydroquinone, liquorice extract, kojic acid and vitamin C. SPF The British Association of Dermatologists (BAD) classify sunscreens into four categories: low protection (SPF 6-14), medium protection (SPF 15-29), high protection (SPF 30-50) and very high protection (SPF 50+).52 The organisation recommends individuals opt for a sunscreen with an SPF of 30 or higher, as does the American Academy of Dermatology.53 With no official photoageing treatment protocols, photoprotection involving yearround broad spectrum sunscreen with sun protection factor (SPF) 30 UVB protection and five-star UVA would be advisable. This should be teamed with sun avoidance during peak UV hours53 and UV protection factor (UPF) rated clothing.54 Sunscreen application at the recommended dose of 2mg/cm2, 1530 minutes before exposure and replenished every two-to-three hours or after swimming and exertion is vital.55 Sun creams are classed as photoabsorbers (avobenzone and benzophenones) and photoreflectors (titanium dioxide and zinc oxide) but can be a combination of the two.56 High-factor photo absorbers can contain harsh chemicals filters capable of generating photoallergic skin reactions, hormone disruption and increased free radicals in the skin.57-60 Longterm side effects are unknown, hence addition of antioxidants, peptides, and hydrators seems beneficial.61 Some organic non-irritating, water-resistant, and photostable UV-filters include Mexoryl and Helioplex.62,63 Photo reflectors with larger particles are unable to penetrate the stratum corneum, and so are less toxic. However, some individuals find them too opaque.59 The ‘best’ topical cream for photoageing is broad-spectrum sunscreen for morning and daytime application. Current sunscreens are multi-tasking photoprotective moisturisers containing humectants, antioxidants and exfoliants like α-hydroxy acids. Dermatology organisations are evaluating current sunscreen protocols as they prevent vitamin D absorption.64

Histological/ultrastructural features

Clinical effects

Collagen-rich ‘repair zone’ in upper papillary dermis Increased collagen I, III & VII(anchor fibrils) Reorganisation of dermal collagen into woven bundles of fibres Normalisation of elastic tissue organisation Increased angiogenesis

Improvement of coarse wrinkling

Epidermal hyperplasia Compaction of the stratum corneum Thickening of the granular layer Increased epidermal and dermal intercellular mucin deposition

Decreased melanin content Enhanced keratinocyte shedding Reduced size of melanocytes’ Golgi complex and endoplasmic reticulum

Increased skin smoothness and decreased roughness

Improvement of skin discolouration/dyschromia

Figure 4: Summary of retinoid effects on photoaged skin.71

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Cell regulators Cell regulators include retinoic acid, peptides and growth factors and their aim is to increase fibroblast synthesis, which may help reduce the appearance of photoageing.65 Retinoids Vitamin A derivatives are not created equally and need conversion to retinoic acid (RA) by specialised enzymes. Retinol conversion to RA is low and retinyl ester conversion is even lower still:66 Retinyl ester < = > Retinol < = > Retinaldehyde (Retinal) => Retinoic Acid (RA) Retinaldehyde, RA’s nearest precursor, is more likely to match its benefits, however potency issues inhibit its use in OTC products.67,68 Irritation caused by retinoids is also related to the above pathway; retinoid reactions including dryness, peeling, pruritus, stinging and photosensitivity. Hence, retinoid choice may affect patient compliance.69 Oral retinoids are teratogenic and are hence avoided. It is unknown if topical retinoids carry the same risk.70 RA binds with DNA eliciting molecular, histological and clinical changes in photodamaged skin using multiple modes of action (Figure 2).71 RA (tretinoin) is a ‘gold standard’ prescriptiononly substrate when compared with other topical interventions. Although it’s approved by the US Food and Drug Administration (FDA), it does not have a UK licence for treating photodamage. A reminder that the MHRA states that healthcare professionals may have more responsibility to accurately prescribe an unlicensed or off-label medicine than when they prescribe a medicine within the terms of its licence.72 Research suggests that tretinoin 0.025% is as effective as 0.05% or 0.1%, but causes less skin irritation.69 Tazarotene, adapalene and retinyl retinoate, a hybrid retinoid, yield results equivalent to tretinoin, according to the literature.69,73,74 Retinoid reactions can be minimised by starting a lower concentration retinoid, a few times per week, increasing to alternate and then nightly use. Less frequent application is indicated if irritation occurs.71 Prescription retinoids yield smoother skin at one month, pigmentation lightening between two to four months and wrinkle improvement at three to six months after use.69 It’s been reported that improvements continue for up to one year of use.75 Discontinuing treatment results in photodamage, so long-term follow-up with a lower concentration and less frequent application is advised.76 Moisturisation, 30 minutes after application and daily sunscreen is crucial. This is because retinoids become unstable and less active when exposed to oxygen and light, hence packaging and product storage should avoid these factors and night time application is key.77 Peptides These amino acid fragments mimic wound healing, aiming to reduce wrinkles by stimulating collagen and elastin synthesis via growth factor upregulation.78,79 Added to OTC products, their antiageing efficacy is based on unpublished commercial data claiming minimal compositions show significant results in eight weeks; however, medical studies appear to be lacking.80 There are a vast number of peptides available in cosmetics. Pal-KTTKS (matrixyl) is the most widely studied skincare peptide with some supportive data, however studies remain limited and small. Argireline is another peptide that mimics nerve-to-muscle communication like botulinum toxin.81-84

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Growth factors and cytokines These larger molecules increase dermal fibroblast and keratinocyte proliferation inducing extracellular matrix (ECM) formation.80,81 Most topical products contain a combination of growth factors. Cytokines are growth factors which regulate the immune system. They are absorbed by hair follicles, sweat glands and compromised skin.85-88 Some patients may suffer hypersensitivity reactions with them.89 Antioxidants Antioxidants include vitamins, coenzymes and botanicals and aim to scavenge free radicals and ROS, protecting cells and counteracting collagen degradation.59 Sunscreens cannot confer 100% protection; antioxidants prevent photoageing by scavenging free radicals. Oxidative stress reduces enzymatic and non-enzymatic antioxidants of the skin.83 Introducing antioxidants including vitamins C, E and B3, coenzyme Q10 and β-carotene may be beneficial.1 It is not clear which antioxidants are most effective or whether topical and oral combinations perform better and evidence for antioxidant mechanisms is not robust. Antioxidant stability and concentration needs addressing, but there are many studies showing antioxidant combinations work synergistically.90-91 Vitamin C (ascorbic acid): being water soluble it cannot penetrate the stratum corneum and heat sensitivity means it easily degraded by oxidation, hence esterified derivatives are used. Studies using concentrations of 3-20% are documented to induce dermal collagen synthesis and tissue inhibitor of MMP-1.94-96 Clinical studies demonstrating efficacy for melanin reduction, which can improve pigmentation, are limited and research maintaining stability and permeability are underway.97 Vitamin E (α-tocopherol): being lipid soluble and heat resistant, 2-20% concentrations show skin compatibility. α-tocopherol protects lipids in the formulation from oxidation and removes lipid-free radicals, smoothing the skin’s surface and increasing the moisture level of the stratum corneum. This accelerates epithelialisation, stimulates enzymes and acts as a photoprotectant reducing UVB-induced erythema. Both vitamins C and E stabilised with ferulic acid show improved absorption and double the photo-protective and antioxidant effects.98,99 Vitamin B3 (niacinamide): a precursor to a vast number of coenzymes.100 It has shown significant wrinkle and hyperpigmentation reduction in well-tolerated doses of 2-5%.101-103 The main difficulty is preventing its hydrolysis to nicotinic acid, which has been shown to cause erythema. This is avoided by maintaining a pH range of four to seven, hence avoiding salicylic acid and zinc-oxide ingredients.104,105 Coenzyme Q10 (CoQ10/ubiquinone): is fat-soluble and found in the electron transportation chain, demonstrating antiapoptotic activity. CoQ10 diminishes with age and UV exposure. Clinical effectiveness in 0.3-1% concentrations reduces epidermal oxidation, reducing MMP-1 expression in UVA-irradiated human dermal fibroblasts, so improving wrinkle appearance.106-108 Improved bioavailability is demonstrated by encapsulation in lysosomal formulation and soybean phosphatidylcholine.109

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


Botanical antioxidants: include extracts of grape seed, pomegranate, green tea and raspberry, lycopene, coffee berry amongst others which have been shown to have antioxidant potential. They originate from natural plant-based sources. The difficulty in determining their efficacy lies in the lack of scientific clinical trials and even where conducted they have small sample sizes. This is further compounded by a lack of regulation and legislation which varies between countries making quality control complicated.110,111

Summary Wanting only a topical cream to treat photoageing, patients should understand that complete reversal using topical creams alone is not possible and combination treatments may yield better results.112 Further ageing will be minimised but patient satisfaction with the results is questionable. Treating photodamage is not easy with continual ageing so re-evaluation for other treatment methods (e.g. chemical peels, microneedling, dermabrasion, lasers) in future may be required. The topical regime selected should provide a sound foundation, as minimally-invasive treatment results are underpinned by rigorous skincare regimes. With no set protocols for aesthetics procedures in any order, staged approaches to combination therapies are crucial.65

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Dr Priya Shah graduated dentistry in 2002 from Kingâ&#x20AC;&#x2122;s College London and is the founder of Dr Priya Shah Facial Aesthetics, London. She is currently undertaking study for a MSc in Skin Ageing and Aesthetic Medicine. She focuses on delivering natural enhancements alongside educating patients on improving skin health. Qual: BDS

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Advertorial Celluma Light Therapy

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Embracing Change with Celluma

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again. Contactless check-in options and no-touch treatments are now a part of how consumers expect you to do business. And you can be confident that our safety protocols are the best in the business. Celluma is simple to disinfect and the only LED light therapy device with Hygiene Barriers fitting most models. You can now also order Celluma Face Shields for an extra layer of protection when seeing patients. We’re reimagining our business along with you as we manufacture new products (Celluma Face Shields and our new battery-powered Celluma iSERIES) and fine tune our Retail and Reseller Programmes to better meet your needs during this uncertain time. In addition to the Celluma no-touch treatment options you can provide at your location, our Reseller and Retail Programmes can help you recoup income lost over the last several months. Additionally, we can help you set up a Rental Programme so you can rent your Celluma device to your patients, keeping them on protocol, and helping them maintain results between appointments.

Reimagine your business model with Celluma Light Therapy During these recent times of restricted travel and movement, the importance of no-touch services and home health solutions has become more evident. As the picture of what will be the ‘new normal’ becomes clearer, you have two choices to consider. You can either become overwhelmed by the changes or you can use these unique circumstances to reimagine how you do business. From the set-up of your clinic to treatment options to safety protocols, it’s the perfect time to implement new systems to provide your patients or clients the best results, while still keeping them, and you, safe.

While there is no replacement for your expertise, knowledge, and caring touch, we at Celluma have created solutions to bridge the care gap for your patients and reimagine your business model to bring in additional income, even after your doors open again. Our programmes are designed with you in mind. We’re still in this together and that includes working with you to find solutions to address the new requirements involved with reopening your clinics and salons.

Safety and success Safety is a priority for everyone, especially as parts of the world begin to open up

What practitioners say about our Reseller Programme “When I was forced to close our clinic doors due to COVID-19, we had to get creative to keep a revenue stream coming in. Our clients are in need of facials, but how can we treat when we were mandated to shut down? Celluma! The Reseller and drop-ship programme allowed me to treat my clients at a distance, without having to buy product. I’m thankful to Celluma for changing their protocol so we could drop-ship and not have to buy stock during this uncertain time. Thanks Celluma!!” Melissa Fox, L.E., owner of Flawless by Melissa Fox in Coral Gables, Florida

26

Aesthetics | July 2020

Our programmes are designed with you in mind. We’re still in this together and that includes working with you to find solutions to address the new requirements involved with reopening your clinics and salons


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Advertorial Celluma Light Therapy

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Celluma Light Therapy benefits you: Celluma Light Therapy benefits to you and your practice: • Recoup income through our Reseller and Retail Programmes • Rent your Celluma to keep patients on protocol • Choose from 11 LED models for clinic and home use

Celluma is responding to COVID-19 Patrick Johnson, CEO, inventor of the Celluma, and recipient of The DigitRx Award for Product Innovation of the Year at the 2019 Aesthetics Awards, says, “One of our organisational cornerstones is a commitment to compassion – the caring for all those who come in contact with the company. Our first response to the COVID-19 crisis was to ensure that our team members, our suppliers and most importantly, our customers, were safe and healthy, and had the resources to remain so. Beyond that, we feel we have an obligation to take care of our community. We possess unique skills and capacities, whether it be financial, human or manufacturing capital and we are leveraging all three to produce medical-grade face shields that are so critically needed by healthcare workers around the world. It’s our little way of being a part of the solution.”

Safety is a priority To help meet the needs of medical professionals on the front lines, Celluma has pivoted operations to include manufacturing badly needed disposable medical Celluma Face Shields. Celluma engineers have designed a medical face shield the company can produce with material and methods currently used to manufacture its Celluma SERIES of LED light therapy devices. Celluma is now offering these Face Shields to clinic professionals. As clinics prepare to open, staff and patient safety remains a priority. Celluma is also the only Light Therapy device with Hygiene Barriers available for most models.

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Learn more about Celluma Celluma has more medical CE Marks and FDA-Clearances than any LED device. Call +44 (0) 203 981 3993 or email pc@celluma.co.uk to find out more about our safety options, how you can take advantage of our unique Reseller and Rental Programmes and our virtual education to reconnect with your patients and get your clinic back on track.

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Aesthetics | July 2020

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Understanding Dry and Dehydrated Skin Consultant dermatologist Dr Anjali Mahto explores skincare physiology and considerations for dry and dehydrated skin Skin is considered to be the largest organ of the human body, accounting for 12-15% of body weight and covering 1.5 to 2 square metres of area.1 It is a highly dynamic and complex organ with a large number of specific roles. Aside from providing a key physical barrier to the outside world, it is also the site of significant endocrine, immunological and metabolic function. The skin forms part of the vital communication network between the inside and outside world and this is only half the story. The skin is not only an indispensable biological organ, but also functions as a social organ. It plays an important cosmetic role with a significant impact on one’s social interactions, confidence, body image, job prospects and even mate selection. Skin is often, rightly or wrongly, also used crudely as a surrogate marker for the perception of an individual’s general health status. To be able to develop and formulate personal care products to supplement the skin and its numerous processes, it is important to have a solid understanding of the skin’s structure and function in both health and compromised or pathological states.

Structure and function The skin has three main layers, each with its own primary function:2 1. The epidermis, which functions as a barrier preventing loss of fluid and electrolytes as well as offering protection against external insult or injury 2. The dermis, which is the source of structural and nutritional support 3. The hypodermis or subcutaneous fat layer, which offers insulation Whilst skin structure under light microscopy is fairly consistent in most body regions, there are well-recognised modifications in specialised areas such as the palms, soles, genitalia and scalp. Skin thickness can vary across sites, with the epidermis of the eyelid measuring 0.05mm, in contrast with the palms at 1.5mm.3 The epidermis The epidermis is the outermost layer of skin and its main cell type is the keratinocyte, which account for 90-95% of cells. They are key in forming a physical, biological and chemical barrier to the outside world, offering thermal protection as well as keeping out pollution, microbes and allergens. In addition, they are a key site for vitamin D production. The epidermis is arranged in stratified layers to include the basal layer (stratum basale), spinous Dead keratinocyte Lamellar granules

Stratum corneum Granular cell layer

layer (stratum spinosum), granular layer (stratum granulosum) and finally the stratum corneum. In certain areas where the skin is thick (e.g. acral sites such as the palms and soles), there is an additional layer known as the stratum lucidum, which sits between the stratum granulosum and stratum spinosum. In contrast to the other layers, the stratum corneum consists of anucleated cells called corneocytes, which are derived from keratinocytes. Cells from the basal layer migrate and differentiate upwards until they form the stratum corneum. Dead cells are sloughed from the surface in a process known as desquamation. Under normal conditions, it takes two weeks for differentiating cells to leave the nucleated compartment and a further two weeks to move through the layers of the stratum corneum. The skin will therefore renew itself every 28 days.2 The other main cells of the epidermis include melanocytes, Langerhans cells and Merkel cells: • Melanocytes are the pigment-producing cells of the skin. There is approximately one melanocyte for 36-40 keratinocytes. They are found in the basal layer of the skin where they make pigment granules known as melanosomes which contain melanin.3 These are transferred via dendritic processes to keratinocytes where they usually aggregate above the cell’s nucleus. Melanin is responsible for skin colour, in addition to playing a major role in protecting the skin from ultraviolet radiation. • Langerhans cells are the third major resident cell type of the epidermis and play an important role in immune surveillance. They metabolise complex antigenic substances into peptides and, once activated, migrate out of the epidermis into regional lymph nodes, functioning as antigen-presenting cells involved in immunity. • Merkel cells are the final group, which act as mechanoreceptors responsible for light touch sensation.

Langerhans cell

Keratinocyte

Spinous layer

Melanin Melanocyte Merkel cell Basal lamina

Figure 1: The epidermis2

Basal layer

The dermis Beneath the epidermis is a specialised structure known as the basement membrane, which attaches it to the next major layer, the dermis. The dermis is highly vascularised providing both structural and nutritional support to the skin. Its main cell type is the fibroblast which synthesises collagen and elastin.2,3 The dermis can sometimes be further classified into the papillary (upper)

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and reticular (lower) dermis. The papillary dermis is rich in nerve fibres for detection of temperature, pain and itch sensation. The reticular dermis contains a densely packed matrix of collagen and elastin fibres alongside a glycosaminoglycan gel. These act together to give the skin strength, elasticity, and firmness. Blood vessels in the dermis play a key role in transport of nutrients and removal of waste products in addition to thermoregulation. A rise in body temperature triggers the dilation of blood vessels in the skin allowing heat to be lost from the surface and the opposite, constriction, occurs in cold weather in order to conserve heat. In addition to contributing to the skin’s tensile strength, the dermis is the site of key adnexal structures such as the hair follicles, sebaceous glands, apocrine and eccrine glands. These specialised tissues play unique roles in the skin. Hair follicles are found all over the body, except at the acral sites. Sebaceous glands are also attached to hair follicles and, collectively, a hair follicle, its associated arrector pili muscle and sebaceous gland are known as the pilosebaceous unit. Sebaceous glands produce sebum under the control of androgen hormones (e.g. testosterone and dihydrotestosterone) to act as a lubricant for skin. In response to cold or strong emotions such as fear, a contraction of the follicle’s arrector pili muscles occurs, which causes the hair to stand up on end. Eccrine sweat glands can be found all over the body but occur in highest density in the axillae, forehead and acral sites. These aid temperature regulation; when the body needs to lose heat it will product sweat, which evaporates from the skin’s surface causing cooling. Sweat also functions to facilitate excrete organic toxins and heavy metals. Lastly, the apocrine glands – found primarily in the axillae and anogenital region – secrete a viscous, milky, odourless fluid thought to provide pheromone-like activity.2,3 The hypodermis The subcutaneous layer of skin consists primarily of adipocytes. It functions to absorb shock, thereby offering mechanical protection in addition to insulation. Its thickness can vary depending on body site.

Understanding healthy skin Maintaining a healthy skin barrier is largely dependent on the process of desquamation in the epidermis. It will take approximately 28 days for a keratinocyte to migrate and differentiate from the basal layer and eventually be shed from the stratum corneum.2,4 Keratinocytes in the basal layer are the only viable cells of the epidermis. As they travel upwards, they start to lose the ability to undergo mitosis. As keratinocytes differentiate into spinous layer cells their shape becomes more polyhedral, individual cells are held together by proteins known as desmosomes which require calcium-dependent enzymes for their formation. As the cells migrate into the granular layer, they contain keratohyalin granules which consist of proteins (e.g. profilaggrin, loricrin, involucrin, envoplakin) which will eventually form the cornified envelope of the stratum corneum. The cells finally move into the stratum corneum losing their nucleus, other organelles and plasma membrane. Desmosome attachments become weaker and the cells are ultimately sloughed away from the surface.4 Skin disease can occur when this process is disrupted. Decreased shedding of skin cells from the surface will result in ichthyosis, while increased epidermal cell turnover results in psoriasis. Impaired barrier function can be seen in Darier disease as a result of mutations in the ATPdependent calcium pump in the epidermis.4 Dry skin One of the main functions of the epidermis is to prevent water loss and maintain hydration of the skin. Disruption of the barrier can result

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Function

Structure

Barrier

Stratum corneum

Endocrine

Vitamin D production in keratinocytes

Immunological

Langerhans cells

Sensation

Merkel cells

Thermoregulation

Eccrine sweat glands, dermal blood vessels

Photoprotection

Melanocytes

Waterproofing and lubrication

Sebaceous glands

Heat insulation and protection from mechanical injury

Subcutaneous fat

Figure 2: Summary of function of skin. As outlined, the skin has a number of important functions facilitated by its unique structure and resident cell types.2,3

in increased water loss (known as trans-epidermal water loss or TEWL) and dry skin. Cosmetically dry skin has been noted to have a weaker barrier function than normal skin. Impaired desquamation can lead to lower cohesivity of skin cells, and dry skin has been shown to contain lower natural moisturising factors. Reduced barrier function will also facilitate the absorption of products being applied to the skin surface, resulting in irritant contact dermatitis. Pathogens and allergens may, additionally, enter the skin more easily.5 Dry skin on a macroscopic level can appear rough, uneven, flaky, and even fissured. Symptomatically, the skin may feel dry, tight, uncomfortable, painful or itchy. Individual or environmental factors may also work together to produce dryness. Underlying skin disorders (e.g. atopic dermatitis) and increased age, as well as low humidity and temperature, exposure to solvents and some surfactants may contribute to dryness.6 Prolonged use of soaps and surfactants can have a negative impact on the skin barrier. They can emulsify lipids and denature proteins found in the skin, increasing both TEWL and its permeability. Anionic surfactants tend to be the most problematic (e.g. C10-C12 alkyl chains, alkyl sulphates) in contrast to amphoteric surfactants which have a better safety profile. In addition to changing the water and skin surface chemistry, irritants may also potentially alter the natural microbial flora of the skin. Certain bacteria have been linked to higher rates of growth in alkaline pH and may have the ability to displace the normal skin microbiome.7 The stratum corneum and methods for studying barrier function Despite consisting of non-viable cells, the stratum corneum plays several key functions. Not only is it responsible for skin hydration, it functions as the mechanical and permeability barrier, in addition to keeping out reactive oxygen species from the environment, UV from sunlight, and microbes.8 The stratum corneum is 12-16 layers thick. Its overall structure is of a ‘bricks and mortar’ configuration, where the corneocytes form the bricks, and the mortar is composed of intercellular lipids. The interaction between the two is responsible for the stratum corneum to function effectively as a particle and moisture barrier. The very outer layer of the stratum corneum has a slightly acidic pH of 4.5 to 6.5 (sometimes known as the acid mantle) due to sebaceous and sweat gland secretion. The acidic pH has antimicrobial properties.8 Corneocytes are flat and hexagonal in structure and packed in layers. They contain the protein keratin, which binds water, in addition to a second protein known as filaggrin. They have a cornified envelope rather than a plasma membrane and are connected to each other via corneodesmosomes.2,8 Natural moisturising factors and intercellular lipids (ceramides, cholesterol and free fatty acids in a ratio of 3:1:1) are arranged in bilayers surrounding the corneocytes. They are formed

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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in the granular layer of the skin and their hydrophobic properties prevent water loss into the environment.8 Moisture homeostasis in the stratum corneum is maintained by natural moisturisation factors and desquamation. Moisture is also important in controlling the rate of desquamation. In dry conditions, desmosomes remain intact resulting in a build-up of corneocytes and thickening of the stratum corneum. This will be visible as scaly skin.5 There are a number of methods by which stratum corneum barrier function can be measured. It is commonly classified into physical, instrumental and biological:5 • The physical method typically includes tape stripping or stripping of the stratum corneum using cyanoacrylate glue. Microscopy is then used to visualise, and directly quantify, the cells removed. This method is useful in assessing the quality and efficacy of skincare formulations. • Instrumental methods include measuring TEWL directly using an evaporimeter or inferentially via the skin’s electrical properties (e.g. using Corneometer or SkinChip technology). Other methods measure epidermal thickness using confocal microscopy or, in the research setting, MRI (which can be helpful in providing information on the internal structures of the epidermis and observing improvements with treatment).5,9 • Biological methods to look at ultrastructural details of the stratum corneum and intercellular spaces utilise transmission electron microscopy, field emission scanning electron microscopy and immunofluorescence confocal laser scanning microscopy.5

Product formulation strategies for dry skin Moisturisers are an important part of daily skincare and their main goals are to maintain skin integrity, improve appearance by retaining water content, preventing TEWL and assisting the skin’s natural barrier repair mechanism. Clinical signs of dry skin (xerosis) will appear when the water content of the stratum corneum falls below 10%.5 There are many choices available for the components of a moisturiser formulation. Not only does the product need to support natural skin desquamation and maintain a healthy barrier, it also needs to reach a high aesthetic standard acceptable for consumer use. The basic components will usually consist of moisturising agents, water, emulsifier and preservatives. Most day moisturisers will comprise oil in water emulsions, which are light and spread easily.10 There are three main classes of moisturising ingredients: occlusives, humectants and emollients. A well-designed moisturising product for damaged or dehydrated skin will contain a combination of these classes of ingredient for best outcome.6 Occlusive agents prevent TEWL by forming a hydrophobic barrier or film over the skin surface, which reduces evaporation from the stratum corneum. Common examples include petrolatum, lanolin and beeswax. Petrolatum is highly effective, but has an unfavourable ‘greasy’ texture. Lanolin use is generally limited due to its odour and allergenicity.6,10,11 Humectants attract water from the viable epidermis and dermis (and also the environment if humidity is above 80%), which functions to increase corneocyte water content and promote normal desquamation. Glycerin, sorbitol, urea and sodium lactate are all examples of topicallyapplied humectants. Glycerin, in particular, is one of the most commonly used compounds in cosmetic formulations and can be used in a range of different product types including sticks, micro-emulsions and creams.11,12 The third and final class is the emollients, which work by filling in the gaps or spaces between the corneocytes and thereby smoothening the appearance of rough skin. They are usually lipids or oils which repel polar water molecules and limit their passage to the

outer environment. Depending on their inherent properties they can be further classified into protective, fatting, astringent or dry sub-types.11,12 A good moisturiser may also contain special additives such as hydroxy acids, UV filters, vitamins, essential fatty acids and botanical agents depending on the desired end result. Thought must also be given to the medium by which active ingredients are delivered to the stratum corneum (e.g. cyclodextrins, liposomes). Fragrance may be added to mask the odour of other ingredients or to improve the overall aesthetic quality of the product. Preservatives are essential to inhibit microbial growth and prevent lipids in the formulation becoming rancid.11,12 Moisturisers will also require an appropriate emulsifier system for stability and feel to create cosmetically-elegant products. Non-ionic emulsifiers are usually the most common type used in skincare products. These include compounds such as alkoxylated alcohols, fatty acid ethoxylates, and glycol esters.4,12 Creating compounds with a balance of the above components will result in a moisturiser that will help restore water content, as well as improve skin barrier function in skin that has become damaged or dehydrated.

Helping the consumer choose a moisturiser There is no doubt the product market is heavily saturated and helping the consumer pick the right moisturiser for their skin’s needs is vital. I advise practitioners to look out for descriptor terms such as the following, which may help: reduce dryness, improve dull appearance, smooth and soften skin, increase firmness or suppleness, immediate comfort, long-lasting effect, nourishing, non-greasy. The challenge remains for a cosmetic formulator to deliver a product which is effective, causing minimal irritancy or allergenicity, with a minimal presence and pleasant aesthetic or sensory qualities.

Summary The skin is a highly dynamic organ and not simply an inert brick wall, despite the analogy so often used about its ‘bricks and mortar’ structure. Moisturisers can be a useful way of managing damaged or dehydrated skin. If they are well-formulated, they can reduce the impact of both internal and external factors (e.g. prolonged use of harsh surfactants) on stratum corneum permeability. They will also aid the self-repair mechanism of the skin by ensuring water content remains at a level sufficient for normal enzymatic function and desquamation to continue. Special additive ingredients can be used to fine-tune products for specific skincare concerns. Guiding the consumer when the product is ready to market by appropriate terminology can help make individuals make informed choices about product selection. Choosing the right product for the right concern will ultimately enhance the benefit of the treatment. Dr Anjali Mahto is a medical and cosmetic dermatologist at 55 Harley Street in London. She has an interest in acne, rosacea, injectable and laser therapies. Dr Mahto is the author of The Skincare Bible, as well as a member of the British Cosmetic Dermatology Group and a spokesperson for the British Skin Foundation. Qual: MBBCh, BSc, FRCP

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Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Case Study: Administering a TCA peel Nurse prescriber Amanda Wilson shares an introduction to using a medium-depth peel to improve rhytids and pigmentation Consultation A 63-year-old female patient presented to me requesting treatment for rhytids and pigmentation in order to look her best and improve her skin for her upcoming wedding, which was taking place in two months’ time. The patient had previously been a long-term smoker and had undergone previous treatments with toxins and various skincare, with limited results. She didn’t have any significant medical history and had previously only had toxin treatment to the forehead region. During the consultation we discussed all available treatment options. We decided that a medium-depth chemical peel would be the best course of action; the advantage being it would allow for skin tightening as well as textural improvements. I felt that it was also the best option due to the extent of the patient’s smoker lines and depths of rhytids. Other treatment options which were discussed in combination were needling with radiofrequency, pharmaceutical-grade skincare products, botulinum toxin and dermal filler treatment.

Choosing a peel Chemoexfoliation, or chemical peeling, is a commonly-used method of skin ablation using specific caustic agents that result in quick, uniform, predictable chemoablation to a desired depth that ultimately results in an improved appearance to skin.1 The caustic agents used within chemical peels cause controlled keratocoagulation; a denaturation of the proteins in the dermis and epidermis. This results in a release of proinflammatory cytokines and chemokines.2 Consequently, there is an activation of the normal healing response cascade, which includes stimulation and deposition of new dermal collagen and elastin, reorganisation of proteins and dermal connective tissue, as well as regeneration of new keratinocytes.3 This then results in rejuvenation and thickening of the dermis and epidermis. Moreover, the resulting exfoliation that takes place improves superficial and medium-depth pigmentation.3 When deciding the depth of a chemical peel, the following should be considered: type of chemical, concentration, number of applications, Fitzpatrick skin type of the patient, and the condition being treated. A superficial peel will only penetrate the epidermis, medium-depth peels treat the epidermis and papillary dermis, while deep peels allow for controlled tissue injury right down to the reticular dermis (Figure 1).1 A medium-depth peel was suitable for this patient because we wanted to target the papillary dermis layer for her rhytids and pigmentation. This type of peel can have around 10 days’ downtime, so the patient was counselled for this accordingly during the consultation. As medium-depth peels initiate keratocoagulation down to the papillary dermis, they allow for more impactful rejuvenation of the epidermis and dermal layers in one treatment sitting.4 When used correctly, medium-depth peels can demonstrate excellent clinic efficacy for rhytids, actinic Figure 1: Depths of peels1 keratoses, melasma and superficial

acne scarring.4 There are a number of peeling agents on the market (Figure 2). Common medium-depth peels are 70% glycolic and 30-50% trichloroacetic acid (TCA) blends, for example, Jessner’s solution. Many brands also combine peeling agents with their own technology, for example the Obagi Blue Peel, which was chosen for this treatment.5 As it is not significantly absorbed by the skin, it does not produce systemic complications.6 TCA is a popular and commonly-used peel to treat manifestations of ageing, however careful consideration must be made in patient selection as some darker Fitzpatrick skin types can experience hyperpigmentation.4 Higher concentrations of TCA come with high risks of complications such as allergic reactions, toxicity, and ectropion, and are therefore less commonly used.7

Pre-procedure For chemical peels, it’s necessary to prepare the skin pre-procedure. This is done using primers such as hydroquinone and tretinoin or retinol-based products, which aim to increase cell turnover, strengthen the cell membrane and reduce the risk of any pigmentation post treatment.7 For this patient, Obagi Nu-Derm System was prescribed for 18 weeks of treatment beforehand, ensuring that she used Obagi Tretinoin 0.1% for two full tubes. This significantly reduced the risk of post-inflammatory hyperpigmentation, which can be of concern when administering medium-depth peels.7 Use of a broadspectrum sunscreen of at least factor 30 was also recommended.

Treatment After thoroughly cleansing the skin, the peel was applied. The chemical peel selected was the Obagi Blue Peel; 2ml of a 30% TCA peel was mixed using the Obagi Blue Peel base, which equates to a concentration of 20% TCA Obagi Blue Peel. Proper application technique is critical with medium-depth peels to avoid inadvertent reapplication of the solution. Clinicians should treat the face sequentially by applying to the forehead and temples first, followed by cheeks and chin, and finally the delicate areas around lips and eyelids, as was done with this patient. The peel was then carefully feathered around the jawline and brow areas to prevent obvious areas of demarcation.5 The treatment took around 30 minutes and the patient was advised that a bluish tint would remain on the skin but usually washes off within 24 hours. She was informed that her skin would begin to peel within the next two to three days and

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Basic Chemical Peels

Advanced Chemical Peels

Very Superficial

Medium

• • • • • •

• •

AHA: glycolic 20-35%, lactic 50% BHA: salycylic acid 20-30% TCA 10-20% Jessner’s 1-3 coats Tretinoin and retinol (Microdermabrasion 2 passes)

Minimal downtime All skin types

Superficial • • • •

Injury to epidermis

AHA: glycolic 70% TCA 20-30% Jessner’s 4-7 coats Solid carbon dioxide

TCA 35-40% TCA 35% with: • Glycolic 70% • Jessner’s • Solid carbon dioxide

Deep • • •

TCA ≥40% Phenol 88% Baker-Gordon formula

Injury to dermis Significant downtime Risk of pigmentary changes and other complications

Figure 2: Some types of chemical peels1

Amanda Wilson is a nurse prescriber with a BSc (Hons) in Adult Nursing and is currently undertaking a Post Graduate Diploma in Aesthetic Medicine. She has worked in aesthetics for six years at a number of London clinics, including The Clinic by Dr Mayoni. Wilson is one of the lead trainers at Healthxchange Pharmacy, where she runs training and manages courses for botulinum toxins, Obagi Nu-Derm Systems and the SmartMed equipment portfolio. Qual: BSc (Hons) RN, INP Figure 3: Patient before, during and seven days’ post Obagi Blue Peel

should be healed between the seventh and 10th day.

Result and post-treatment care A long-term maintenance programme with topical agents is necessary to preserve the results of chemical peels and prevent recurrence. Post-treatment care should incorporate broad spectrum, high factor sunscreens and bleaching agents.7 The patient was prescribed Obagi Nu-Derm products for aftercare which incorporate cleansers, toners, hydroquinone, alpha hydroxy acids, moisturisers and SPF protection. A follow-up appointment was scheduled three months after the treatment, in which we discussed treatment satisfaction and ongoing skincare maintenance. The patient was very happy with treatment results and could see an improvement in her rhytids, pigmentation and pores. She also had kept a peel diary to monitor the results from the peel and indicated that 10 days post-peel application, her pores were diminished, fine lines had improved and her skin felt glowing and soft.

Potential side effects and complications For medium-depth peels, the complications which can occur are post-inflammatory pigmentation, superficial bacterial or fungal infection, reactivation of herpes simplex virus, scarring, milia, acneiform eruption and greater thickness desquamation/ epidermolysis.8 The patient did not experience any of these complications as a result of treatment.

Summary Chemical peels can be used for the treatment of pigmentary disorders, textural improvements, rhytids and scarring. The depth of peel selected will make a difference to the treatment outcomes and downtime for the patient. In my experience, priming the skin with Obagi Nu-Derm System drastically reduces the risk of post inflammatory hyperpigmentation post procedure and also enhances treatment results.

Key considerations for medium-depth peeling • • • • • •

Patient selection and assessment is key Prime the skin prior to medium to deep depth peels Be wary of the complication risks and how to deal with these should they occur Discuss downtime with the patient before deciding on the correct peel type to use Manage patient expectations for best results Consider combination treatments

REFERENCES 1. Soleymani, T., Lanoue, J., & Rahman, Z. (2018). A Practical Approach to Chemical Peels: A Review of Fundamentals and Step-by-step Algorithmic Protocol for Treatment. The Journal of clinical and aesthetic dermatology, 11(8), pp.21-28. 2. Baker TJ, Gordon HL. (1986) Chemical face peeling. In: Baker TJ, Gordon HL, editors. Surgical Rejuvenation of the Face. Maryland Heights, MO; C.V. Mosby: pp. 230–232. 3. Smith V., (2016) An Overview of Chemical Peels. The PMFA Journal, 3, 6. 4. Fischer TC, Perosino E, Poli F, et al. (2010) Cosmetic Dermatology European Expert Group. Chemical peels in aesthetic dermatology: an update 2009. J Eur Acad Dermatol Venereol. 24(3):281–292. 5. Hassan KM, Benedetto AV. (2013) Facial skin rejuvenation: ablative laser resurfacing, chemical peels, or photodynamic therapy? facts and controversies. Clin Dermatol. 31(6):737–740. 6. Lober, C.W., (1987). Chemexfoliation—indications and cautions. Journal of the American Academy of Dermatology, 17(1), pp.109-112. 7. Nikalji, N., Godse, K., Sakhiya, J., Patil, S., Nadkarni, N. (2012). Complications of Medium Depth and Deep Chemical Peels. J Cuban Aesthet Surg. 5(4). pp.254-260 8. Marta I et al., (2010) Evidence and Considerations in the Application of Chemical Peels in Skin Disorders and Aesthetic Resurfacing. Clin Aesthetic Dermatol; 3(71). FURTHER READING • Drake, L.A., et al., Guidelines of care for chemical peeling. Journal of the American Academy of Dermatology, 33(3), 1995, pp.497-503. • Fabbrocini, G., De Padova, M.P. and Tosti, A., (2009). Chemical peels: what’s new and what isn’t new but still works well. Facial Plastic Surgery, 25(05), pp.329-336. • Khunger, N., (2008). Standard guidelines of care for chemical peels. Indian journal of dermatology, venereology, and leprology, 74(7), p.5. • Otley, C.C. and Roenigk, R.K., (1996). Medium-depth chemical peeling. In Seminars in cutaneous medicine and surgery. Vol. 15, No. 3, pp. 145-154. • Perkins, S.W. and Balikian, R., (2007). Treatment of perioral rhytids. Facial plastic surgery clinics of North America, 15(4), pp.409-414. • Reserva, J., Champlain, A., Soon, S.L. and Tung, R., (2017). Chemical peels: indications and special considerations for the male patient. Dermatologic Surgery, 43, pp.S163-S173.

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Altered keratinocyte proliferation causes follicular plugs to form at the hair follicle, also known as micro-comedones or whiteheads. These microcomedones are the target lesion for successful treatment of acne. This process can be further exacerbated by excess sebum production, secondary to androgens during puberty. Proliferation of the anaerobic propionibacterium acnes bacterium within the hair follicles causes further inflammation and lesions to form. Other factors thought to play a role in the development of acne include diet, hormonal changes, genetics and drugs.3,4 There are two different types of lesions that practitioners need to be familiar with when assessing acne. The first are inflammatory lesions, which are comedones that can be open (blackheads) or closed (whiteheads) and the second are non-inflammatory lesions, such as papules, pustules and nodules or Aesthetic practitioner Dr Aneesha Ahmad cysts. Blackheads are caused by enlarged provides an introduction to acne assessment and stretched pores with a build-up of excess melanin and oxidised oil.1 Papules and pustules Acne is a common skin condition which affects up to 95% of are superficial lesions which are raised and less than 5mm in adolescents and can occur in up to 43% of adults in their 30s.1,2,3 diameter; pustules are fluid filled whereas papules are not. Despite being more common and severe in male teenagers, Nodules and cysts are larger than 5mm in diameter. Cysts are it is found to be more frequent and indeed persistent for adult fluctuant swellings, lined by epithelium, containing pus, fluid females.2 Acne is commonly found on the face with clusters or keratin, whereas nodules are similar to papules but larger usually on the cheeks, chin and forehead, although it can also in size (5-10mm). Cysts can be painful and may leave large affect the back and chest as these anatomic areas also have scars.4 It is important to recognise the different types of lesions a high density of pilosebaceous units. It is caused primarily which may be present when assessing patients with acne as it by inflammation of the pilosebaceous units, resulting in both will help determine the most suitable and effective treatment inflammatory and non-inflammatory lesions. approaches.6,7 There are thought to be four main processes involved in the development of acne: comedones, microcomedones, papules, Clinical assessment of acne pustules and nodules. If left untreated, acne can cause scarring, There are more than 25 grading systems for acne which have been so it is important for practitioners to be able to identify acne published to date, but there is no universal method for grading or in its mildest form to prevent it from worsening and causing assessing acne.1,8 Due to the dynamic, complex and fluctuating acute 3 scar formation. For this reason, it is essential for an accurate and chronic symptoms, acne can be difficult to evaluate. There are assessment of acne to be carried out, and for clinicians to feel four main recognised methods of assessing acne:9 competent in doing so. 1) Lesion counting Pathogenesis 2) Global acne severity grading Acne development, or pathogenesis, takes place in the 3) Subjective self-assessment pilosebaceous unit, which comprises the hair follicle, sebaceous 4) Multimodal imaging using UVA lamps, fluorescent lights, gland and its exit on to the skin surface as a â&#x20AC;&#x2DC;skin poreâ&#x20AC;&#x2122; (Figure 1). polarisers and a digital camera

Assessing Acne

Figure 1: Formation of acne at the pilosebaceous unit5

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Grade Clear Almost Clear

Description No lesions/barely noticeable – a few comedones and papules Hardly visible from a distance of 2.5m – a few comedones, papules and pustules

Mild

Easily recognisable – less than half the affected area – many comedones, papules and pustules

Moderate

More than half of the affected area – numerous comedones, papules and pustules

Severe

Entire areas – covered with comedones, papules and pustules. A few nodules and cysts

Very severe

Highly inflamed acne that covers the affected area. Many nodules and cysts

Table 1: Assessment of acne with the Comprehensive Acne Severity Scale7

The methods that are most used in clinical settings are lesion counting and acne severity grading.10 Lesion counting Lesion counting involves recording the number of different types of lesions to determine overall severity. It is an objective method and thought to be more accurate, particularly if carried out by the same clinician each time, as it involves recording the specific number of each type of lesion, describing severity down to each individual lesion level.6,9,10 However, due to the level of detail involved, it can be more time consuming. This method can be used in clinical trials or to determine effect of treatment on individual lesions, although it may come across as more intrusive to patients than grading as lesions may be palpated if necessary, which some patients may find uncomfortable.6 It does not take into account other features such as concentration, distribution and size of lesions and erythema. This method relies heavily on the practitioner’s ability to recognise lesions and assess confidently. An example of such a system is the Combined Acne Severity Classification, comprising three categories, and is widely used by practitioners:3,9,10 • Mild acne: fewer than 20 comedones or less than 15 inflammatory lesions with a total lesion count lower than 30 • Moderate acne: 20-100 comedones or 15-50 inflammatory lesions or a total lesion count of 30-125 • Severe acne: More than five cysts, total comedone count more than 100, or total inflammatory count greater than 50 or total lesion count greater than 1256 Severity grading systems Grading systems involve observing dominant lesions and estimating the extent of involvement. It is often criticised as being a subjective system and less sensitive to change and therefore less accurate, but Adityan et al. and Agnew et al. consider this method to be more useful in a clinical setting as it is less time consuming.8-11 The efficacy of treatment on individual lesions cannot be estimated. Examples of different grading systems include the Leeds Revised Grading System and the Global Acne Grading system.1,6 The Leeds Revised Grading System, established in 1998, uses photographs

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in order to grade acne of the face, back and chest. There are 15 facial grades and eight each for the chest and back. These grades are based on a selection of more than 1,000 photographs from a panel of three dermatologists and four acne assessors. The clinician compares the photographs in the system to the clinical appearances of their patient. However, this system can be difficult to apply in clinical practice due to the varying representations of severity and the large number of categories within each region.6 A more commonly used system is the Comprehensive Acne Severity Scale, which has a strong correlation to the Leeds Grading System and is simpler to use (Table 1).7

Current guidelines The current National Institute for Health and Care Excellence (NICE) guidelines in the UK acknowledge that although there is no universal system used to score acne, categorising into mild, moderate and severe may help to ensure treatments are selected correctly and to allow treatment response to be monitored.4 With similar classification to the Combined Acne Severity Classification, the following system is suggested by NICE and is slightly different:4 • Mild: predominantly non-inflamed lesions (open and closed comedones) with few inflammatory lesions • Moderate: more widespread with an increased number of inflammatory papules and pustules • Severe: widespread inflammatory papules, pustules and nodules or cysts. Scarring may also be present

Psychological assessment It is also important for practitioners to acknowledge and assess the psychological impact of acne, as well as the physical implications. Studies have shown that in some cases, even mild to moderate acne may be associated with significant depression and suicidal ideation and the effects of acne are comparable to other chronic diseases such as asthma, epilepsy, diabetes and asthma.8,12,13,14 Measuring quality of life allows practitioners to understand the patients’ perspective of disease and there are many scales which allow clinicians to assess the impact of acne upon quality of life. There are several examples of psychological assessment tools, including the Acne Disability Index, the Acne Quality of Life scale and the assessment of psychological and social effects of acne. Questions

Response

Score

1. Have you felt aggressive, frustrated or embarrassed due to your acne?

Very much A lot A little Never

3 2 1 0

2. Do you think acne has interfered with your social life and relationship with the opposite sex?

Severely Moderately Occasionally Never

3 2 1 0

3. Have you avoided wearing swimming costumes or clothes which may expose areas of your trunk with acne?

Always Mostly Occasionally Never

3 2 1 0

Very depressed Usually concerned Occasionally concerned Never

3 2 1 0

Worst Major problem Minor problem No problem

3 2 1 0

4. Have you been concerned about the appearance of your acne? 5. Does your acne pose a problem to you now?

Table 2 Cardiff Acne Disability Index15

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


One of the more popular scales is the Cardiff Acne Disability Index (Table 2), which comprises five questions.6,8 A score of 0 equates to no impairment, 1-5 mild impairment, 6-10 moderate impairment and 11-15 severe impairment. Early identification of patients with acne who may be at risk of impaired quality of life allows practitioners to take early intervention such as psychological support, in addition to medical management, thus improving social and psychological wellbeing of such patients.

Putting it into practice Although there is no agreed upon universal method for assessing acne, it is apparent that clinicians should be confident in identifying and distinguishing between different lesions to correctly treat acne. Clinicians should choose a method of assessment that they are comfortable and confident with. It is vital that the impact on the quality of life of such patients is taken into account as psychological support is often needed. Ultimately, the goal in the management of acne is alleviating symptoms, clearing lesions, limiting disease progression and avoiding scar formation, alongside alleviating any negative impacts on quality of life. Accurate assessment of the condition therefore provides the cornerstone for the correct management of acne.

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Dr Aneesha Ahmad qualified in 2008 from the University of Manchester. She works as a GP principal with a special interest in dermatology, having completed her Diploma in Practical Dermatology with distinction. Dr Ahmad is a trainer in advanced aesthetics and the founder of Skyn Doctor, Huddersfield. QUAL: BSc(MedSci) MBCHB, MRCGP, PG Dip Dem (Distinction) REFERENCES 1. Ramli R, Malik A Et al, Acne analysis, grading and computational assessment methods: an overview, Skin Research and Technology, 2012 2. Skroza.N, Tolino.E Et Al, Adult Acne Versus Adolescent Acne, The Journal of Clinical and Aesthetic Dermatology, 2018 3. James Leveson and Dr Karolina Gholan, Acne vulgaris: clinical review, www.gponline.com, 2017 4. Adityan B, Kumari B, Thappa D M, Scoring systems in acne vulgaris, Indian Journal Dermatology, Vol 75 Issue 3, 2009 5. The Pharmaceutical Journal, 2017 6. Jerry KL Tan, Current measured for the evaluation of acne severity, Expert Review Dermatology, 2008 7. Van Onselen J, Managing acne in Primary Care, British Journal of Family Medicine, 2017 8. Hazarika N, Archana M, The Psychosocial Impact of Acne Vulgaris, The Indian Journal of Dermatology, 2016 9. Agnew T, Furber G, Et al, A comprehensive critique and review of published measures of Acne severity, The Journal of Clinical and Aesthetic Dermatology, 2016 10. Adityan B, Kumari B, Thappa D M, Scoring systems in acne vulgaris, Indian Journal Dermatology, Vol 75 Issue 3, 2009 11. Lehmann HP, Robinson KA Et Al, Acne therapy: A methodologic review, Journal of American Academic Dermatology, 2002 12. Thomas D.R, Psychosocial Effects of Acne, The Journal of Cutaneous Medicine and Surgery, 2005 13. Halvorsen J, Stern R Et Al, Suicidal Ideation, Mental Health Problems, and Social Impairment Are Increased in Adolescents with Acne: A population based study, Journal of Investigative Dermatology, 2011 14. Uhlenhake E, Tentzer B Et Acne Vulgaris and depression: a retrospective examination, Journal of Cosmetic Dermatology, 2010 15. Shams N, Niaz F, Zesshan S, Et al, Cardiff Acne disability Index based Quality of Life in Acne Patients, risk factors and Assosications, J Liaquat Uni Med Health Sci, 2018

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Using the BELOTERO® Range Dr Paula Mann (BDS) provides an overview of the BELOTERO® dermal filler range and explains why she uses the products to create predictable, harmonious results1,2 tailored to her individual patient needs Why do you choose the BELOTERO® range? I have been using BELOTERO® for the last five years with great results for my patients. For me, the difference is in the way the BELOTERO® range is created. For full face natural rejuvenation it is really important I can address the changes within the different tissue layers. The BELOTERO® range provides me with a rheologically-tailored portfolio, with each filler having its own unique benefits at varying injection depths. I can treat patients as individuals, not with a one size fits all approach. It is also vital to me that I use a filler with evidence of an established safety profile. I am confident in my choice as research has shown the BELOTERO® range of fillers demonstrate little or no immune inflammatory response in the tissue.1,3

Why is rheology so important? BELOTERO® hyaluronic acid (HA) dermal fillers are the only fillers available to UK and Ireland practitioners manufactured using the patented Dynamic Crosslinking Technology (DCLT), leading to a Cohesive Polydensified Matrix (CPM). The resultant monophasic gel has variable densities of crosslinked HA. This gives excellent tissue integration as the filler will respond to the different areas of interstitial volume loss.4 For myself and my patients this is seen as a natural, smooth correction. By manipulating the three main important rheological properties (cohesivity, elasticity and plasticity), BELOTERO® has created a portfolio of fillers which are optimised in the superficial, subcutaneous and deep dermis or supraperiosteal layers.

How does this influence your use of the BELOTERO® range? A filler with high cohesivity can integrate into the tissue without dispersing during movement, giving a smooth, precise result. In my opinion, fillers with high cohesivity such as BELOTERO® Balance and BELOTERO® Lips Contour are perfectly suited to the vermillion border and fine lines.5,6 Here the product will easily flow through a 30G needle and I can inject precisely in the superficial to mid dermis to create sharp definition or correction. Importantly, due to its excellent tissue integration will help prevent migration into the surrounding tissues.7 In those patients who have fine superficial lines, such as crow’s feet or on the décolletage, I inject BELOTERO® Soft directly into the superficial to mid-dermis. With its slightly lower concentration of HA and very high cohesivity it has the effect of ‘airbrushing’ imperfections and

BELOTERO® used in combination or alone helps me achieve a natural looking, long lasting result 42

Aesthetics | July 2020

providing rehydration.8 BELOTERO® Intense and BELOTERO® Lips Shape are the most elastic of the range. This is essential in very dynamic areas such as the lips, nasolabial folds and marionette region. I use a cannula or 27G needle to place these in the deep dermal tissue to augment and revolumise the lips and smooth deeper lines. Its elasticity makes it resistant to the shearing and compressive forces it encounters; it will project and volumise, while giving a beautiful, natural looking result.9 When restoring deeper volume loss or improving contour in 3D, such as the temples, cheeks and chin, I need a filler which is highly plastic to enable shaping and moulding. However it must be sufficiently elastic for lifting the tissues and maintaining a natural result in facial expression. BELOTERO® Volume has a combination of both properties.9,10 To create a balanced, restored facial shape I prefer to inject this filler onto the periosteum of the cheek bone and chin using a 30G or 27G. In the sub-SMAS and deep subcutaneous layers of the anterior mid-cheek and sub malar areas, I would use a cannula for creation of smooth flowing contours and natural features. More recently, Merz launched BELOTERO® Lips Shape and BELOTERO® Lips Contour. These are the same formulations as BELOTERO® Intense and BELOTERO® Balance, respectively. Together, 0.6ml of Shape and Contour are a lip enhancement duo, designed to address the age-related changes in the two different lip tissues. Both myself and my patients absolutely love this combination treatment. I explain that together these fillers act like lipstick and lipliner.


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Case Study: BELOTERO® full face rejuvenation This 50-year-old male patient was concerned about looking tired and old, and wished for a rejuvenating result that maintained his masculine features but would not be noticed by his peers. Presentation Full face analysis revealed global volume loss. In the temples this formed an hourglass appearance and contributed to lateral brow ptosis. There were fine static lines in the forehead and orbital region. There was also significant volume loss in the midcheek area leading to a more significant lower lid cheek junction, Before

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Treatment The temples were treated with supraperiosteal injections of BELOTERO® Volume 0.5ml per side, while the right and left anterior and lateral mid-cheek were treated using supraperiosteal depot injections of BELOTERO® Volume 0.7ml, blended with 0.7ml subcutaneous placement of BELOTERO® Volume using a cannula. 1ml of BELOTERO® Volume was again used supraperiosteally on the anterior projection point of the mandible to balance the retroclined position of the pogonion. A further 0.5ml of BELOTERO® Volume was injected as a supraperiosteal bolus on the gonial angle to create width. A cannula was used in the deep dermis of the more After

nasolabial folds and flattening in profile. Loss of support at the oral commissures and fine perioral lines led to a ‘sad’ appearance and there were obvious marionette folds. The chin was retroclined when compared to the nasal projection and the gonial width was narrow, creating an imbalanced proportion compared to the overall facial length. Following discussion with the patient, including benefits and risks, he consented to an initial treatment plan focussing on correction of fine lines, volume replacement and creating balance.

dynamic areas with 0.5ml of BELOTERO® Intense, used in each of the nasolabial and marionette folds. This had the effect of smoothing the deeper lines and lifting the oral commissures. Using a 30G needle in the superficial dermis the fine static lines around the lateral orbits of both sides were corrected using 0.4ml of BELOTERO® Balance. Careful analysis and use of the appropriate BELOTERO® dermal fillers at the varying levels of need resulted in a natural looking rejuvenation. The patient was delighted and has committed to further treatment and maintenance over the coming months.

The very elastic Lips Shape comes in a 0.6ml syringe and is perfect for natural volumisation of the vermillion. The highly cohesive Lips Contour 0.6ml is a sufficient quantity to inject in the superficial dermis of the vermillion border giving a sharp, more youthful defined border and reduction in perioral wrinkles.7

Conclusion It is essential I can analyse my patients face and have the available tools to meet their needs; rejuvenating in an effective, predictable and natural way. The CPM fillers of the BELOTERO® range are not about painting by numbers for a generic look. The products have been specifically created to achieve natural looking, lasting results. I am confident I am using a dermal filler with an excellent safety profile,10 predictable, harmonious results and high patient satisfaction and trust.1,2 Dr Paula Mann qualified as a dental surgeon in 2000. She worked in her own private practice and as a clinical teacher at The University of Glasgow’s Dental Hospital. Having introduced non-surgical aesthetic medicine to her clinical practice in 2008, this soon became Dr Mann’s main focus. She is now solely committed to the practice and teaching of aesthetic medicine within Clinetix Medispa and Aesthetic Training Academy in Glasgow. Dr Mann joined the team at the Merz Institute of Advanced Aesthetics as a Merz Innovation Partner in 2019 supporting practitioners using the Merz portfolio. Qual: BDS (Hons)

THIS ADVERTORIAL WAS WRITTEN AND SPONSORED BY

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REFERENCES 1. Prasetyo AD et al. Hyaluronic Acid Fillers with cohesive polydensified matrix for soft tissue augmentation and rejuvenation: a literature review. Clin Cosmet Investig Dermatol. 2016 Sep 8;9:257-80. 2. Buntrock H, et al. Efficacy, safety and patient satisfaction of a monophasic cohesive polydensified matrix versus a biphasic non animal stabilised hyaluronic acid filler after single injection in nasolabial folds. Dermatol Surg, 2013 Jul;39(7):1097-105. 3. Taufig A, et al. A new strategy to detect intradermal reactions after injection of resorbable dermal fillers. Jn Aestheitc Chir. 2009;2:29-32. 4. Tran C et al. In vivo Bio integration of three hyaluronic acid fillers in human skin: A histological study. Dermatology, 2014;228(1):47-54. 5. Instructions for Use (IFU) Belotero + Lips Contour 6. Instructions for Use (IFU) Belotero(R) Balance 7. Fischer TC et al. Hyaluron Filler Containing Lidocaine on a CPM Basis fir Lip Augmentaion: Reports from Practical Experience. Facial Plast Surg. 2016 Jun;32(3):283-8. 8. Micheels P, et al. Plastic Reconst Surg. A Blanching technique for the intradermal Injection of the Hyaluronic Acid BELOTERO®. 2013Oct;132(4Suppl 2):59S-68S. 9. Garvard Mollinard S, et al. Key Importance of Compression Properties in the Biophysical Characteristics of Hyaluronic Acid Soft tissue Fillers Jn Mechanical Behav Biomed Materials. 2016 Aug;61:290-298. 10. Micheels P et al, Treatment of Mid Face Atrophy by Injection of Cohesive Polydensified Matrix Hyaluronic Acid Volumiser. Jn Clin Aesth Derm 2015;8(3);28-34.

Adverse events should be reported. Reporting forms and information for United Kingdom can be found at www.mhra.gov.uk/yellowcard. Reporting forms and information for Republic of Ireland can be found at https://www.hpra.ie/homepage/about-us/report-an-issue/mdiur. Adverse events should also be reported to Merz Pharma UK Ltd by email to UKdrugsafety@merz.com or on +44 (0) 333 200 4143.

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Exploring Innovations and Technology in Photoprotection Consultant plastic surgeon Mr Paul Banwell explores the latest research and evidence in suncare The mantra that sun protection factor (SPF) is the most important antiageing manoeuvre available at our disposal is now firmly entrenched within the aesthetics specialty; yet, surprisingly, this has only been accepted within the last decade. Prior to this there was a disconnect between the use of SPF and its impact on ageing; it was only associated with skin cancer prevention by aesthetic practitioners and the public alike. Hughes and colleagues’ 2013 randomised study confirming the link between use of sunscreen and prevention of skin ageing was truly a seminal event and cemented the connection.1 Indeed, within the last five years especially there has been an explosion in advancements in sunscreen technologies and in the whole concept of photoprotection. Clinicians and cosmetic scientists have developed new strategies and products to include standalone SPFs, topical antioxidants, topical immune protectants, solar botanicals from extremophile plants, oral supplements in capsule or drinkable form (nutraceuticals) or combinations of all of these. This article will describe the latest developments in suncare and how they can be used in practice.

Solar constant and skin damage Our traditional understanding that ultraviolet radiation (UV-A and UV-B) was the only form of deleterious energy causing damage to the skin has now been supplemented by the evidence that the other solar constant components of infrared (IR) radiation and visible light (recently dubbed high energy visible light ‘HEVL’) are also heavily implicated in photodamage too.2,3 The relative proportions of these energy forms and wavelengths

43% Infrared

7% UV

50% Visible Light

Figure 1: Diagram demonstrates the breakdown of solar constant sources that can cause damage to the skin35

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are highlighted in Figures 1, 2 and 3, as well as the specific importance of ultraviolet radiation. These insights have spawned a huge proliferation of sunscreen manufacturers changing their formulations and marketing claims, meaning our patients can now benefit from this advancing knowledge. Interestingly, certain innovators in Australia (which leads the way in photoprotection knowledge and research) have been ahead of the game and have offered this for some years, however the rest of the medical community have been slower to adopt these ideas.

Protection methods Sunscreens Unfortunately, the human skin is a very susceptible target organ to UV radiation (UVR). The acute photochemical reactions that occur in the skin secondary to UVR (280-400 nm) are characterised by various inflammatory cascades that are mediated by several possible mechanisms including (a) direct action of photons on DNA, (b) generation of reactive free radicals and reactive oxygen species (ROS) and (c) generation of inflammatory mediators e.g. prostaglandins, histamine and leukotrienes. In turn, repeated acute responses result in adaptive and chronic changes within the skin. These are manifested clinically as classical signs of photoageing and as actinic lesions or skin cancers.4 Sunburn inflammation (erythema) is the most conspicuous and well-recognised acute cutaneous response to UVR, particularly in fair-skinned individuals, and is associated with the classic signs of inflammation, namely redness, warmth, pain and swelling. It is well established that UVR exposure suppresses cutaneous cellmediated immunity in humans. The depletion of Langerhans cells (the principal antigen-presenting cells in the epidermis), recruitment of macrophages into the dermis and epidermis, and release of inflammatory mediators such as TNF-a area, are all important events in the initiation of the concept of photoimmunosuppression (PIS).5 It is known that sustained episodes of cutaneous PIS play an important role in the emergence and growth of skin cancers. This concept is supported by evidence of transplant patients on (chemo)immunosuppressive therapy who display an elevated risk of both non-melanoma and melanoma skin cancer formation.6 Sun (UV) creams have traditionally been the first defence against these UV-mediated processes and PIS. Professor Franz Greiter is generally credited with introducing the concept of Sun Protection Factors (SPF) in 1962, after Schulze had already experimented with commercial sunscreens in 1956. The SPF metric is a measure of the ability of the sunscreen to protect against sunburn; interestingly, the FDA proposed defining the SPF as the ‘Sunburn’ Protection Factor to increase clarity as to what the test actually measures.7 For the lay person, SPF is popularly interpreted as how much longer skin covered with sunscreen takes to burn compared with unprotected skin. Chemical vs. mineral There are two main types of sun cream – chemical (organic) and mineral (which may also be known as physical or inorganic). The main difference is that chemical suncare products contain UV-filtering

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Ultraviolet shortwave (UV-C)

middle wave (UV-B)

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Visible light longwave (UV-A)

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InfraRed

penetration of such nanonised formulations. While they are generally considered safe, ongoing research is required.10

Superfluid-like formulations Taking the concept of cosmetic elegance 200 280 315 400 Wavelength in nanometers (nm) 760 further in sunscreens is the concept of Figure 2: Diagram demonstrates the wavelengths associated with the solar constant.36 superfluid-like formulations. These take their origins from the ideas of superfluids ingredients that take time to be absorbed by the skin – hence people (helium) discovered in the 1930s by Leitner. Superfluidity is using the 20 minute rule before sun exposure. By contrast, mineral the characteristic property of a fluid with zero viscosity, which sunscreens contain inert UV protective ingredients such as zinc oxide therefore flows without any loss of kinetic energy. This discovery and titanium dioxide and form a protective barrier on top of the skin, defied the conventional laws of physics and has spawned and these have an immediate effect.8 further research in multiple industries. These ideas have also What is more, some people who suffer allergies or sensitivities to recently been adopted in the arena of cosmetic science for the chemical UV filters find that mineral sun creams do not irritate their development of liquid microfilms, which spread rapidly over skin. Zinc is also known to be a potent anti-inflammatory agent the skin and, in the case of SPFs, provide improved coverage and does not block pores.9 Chemical sunscreens offer good and protection as well as the ability to integrate multiple other protection from both UVA and UVB rays. The most popular UVA actives. Rationale skincare in Australia was the first to champion and UVB filters include benzophenone, avobenzone, parsol and this concept (e.g. B3-T, Beautiful Skin SPF) but other companies cinnamates. However, the chemical filters parsol and cinnamates including La Roche Posay (e.g. Anthelios) and Kiehls (e.g. Superfluid may sometimes irritate sensitive skin but the main skin irritant – SPF) have developed similar products. the UVB-filtering ingredient PABA (para-aminobenzoic acid) – has been phased out of most sunscreens.9 Some small in vitro studies Supportive suncare measures demonstrating that some of these filters passed through the skin was picked up by the international media creating a backlash on Antioxidants sunscreen use, despite the FDA declaring them as safe and having One of the key sequelae of UV exposure is the generation of oxygenbeen used for many years.9 free radicals and reactive oxygen species. As explained, these In contrast, mineral sunscreens such as zinc oxide or titanium dioxide cause both photoageing and skin cancer. Antioxidants are powerful now form the cornerstone of most SPF preparations – they afford molecules which can safely interact with free radicals and terminate excellent physical protection and they are also less sensitising than the chain reaction before vital molecules are damaged. Although chemical filters. However, opaque inorganic oxide formulations lack there are several enzyme systems within the body that ‘scavenge’ cosmetic acceptability, with a reported trend towards lower and free radicals, the principal micronutrient (vitamin) antioxidants are insufficient application rates.9 vitamins A, C and E. Additionally, selenium, a trace metal that is Making the particles smaller using micronised or nanonised required for proper function of one of the body’s antioxidant enzyme formulations has therefore become common – nanoparticles of systems, is sometimes included in this category.11 titanium and zinc are transparent in formulations spread on the skin In the past decade the role of antioxidants in medical skincare surface. This transparency provides the cosmetic elegance that is has been well established via a multitude of high-quality studies.12 just not achievable with larger-particle formulations. However, a few There are two types of antioxidants we can use – those found years ago some authorities claimed that as dermally-administered naturally in the body (endogenous) and those found outside the nanoparticles are known to localise to regional lymph nodes via body (exogenous), either derived from nature or synthesised in a skin macrophages and Langerhans cells, they were dangerous laboratory. Of all the exogenous antioxidants, the most popular is and should not be used. Subsequent studies have revealed lack of green tea extract, and it has been utilised in cosmeceuticals for some time. Fortunately, the skin also has its own antioxidant system, and I believe this is where we should direct our search in terms of the most wavelength effective antioxidants.11 The so-called Human Skin Antioxidant Complex comprises vitamins 400nm 315nm 280nm 100nm A, C and E together with a group of enzymes, predominately UVA UVB UVC superoxide dismutase, glutathione S-transferase and catalase. In young skins, these antioxidants are found in abundance, but as we age, our natural levels almost half with each decade of life. Ozone Layer Unfortunately, our reserves are also easily diminished by even a single exposure to UVR. For example, after 30 minutes in the sun, the vitamin A and C levels in an average 40 year old are depleted by • Extremely dangerous • Premature • Skin cancer almost 90%.13 Vitamins A, C and E must be included at a dosage high • Blocked by Ozone Layer ageing • Cataracts • Wrinkling of • Sunburn enough to ensure effective antioxidant protection, and these levels the skin have been well elucidated. One of the most recent findings about Figure 3: Diagram • Implcated in to illustrate the relationship of ultraviolet radiation wavelength and skin damage37 skin cancer vitamins A, C and E is that they are synergistic, meaning that they recycle each other as they are used up, ensuring a constant return to Figure 3: Diagram to illustrate the relationship of ultraviolet radiation wavelength and skin damage37 ground state where they are able to reload and fire again and again

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(so-called ‘redox’ reaction).13 Interestingly, enzyme antioxidants are more problematic as they are usually highly unstable outside the human body. However, recent innovations in biotechnology have provided us with skin identical enzymes such as glutathione, catalase and CoEnzyme Q (ubiquinone) which function as fullstrength antioxidants.11 Whilst the endogenous antioxidant system comprising vitamins, enzymes and chromophores are extremely powerful, there are also a host of recently-discovered botanical antioxidants that are many times more potent and equally effective.14 In my experience, the best topical products contain all of these biomolecules as they are all equally important and synergistic. The difficulty is that these substances are inherently unstable and dose dependent, making precise formulation imperative. By definition, topical antioxidants will therefore confer many benefits from not only an antiageing perspective, but just as importantly from an anti-skin cancer perspective and thus should be used as part of a daily skincare regime for UV protection. Daily use of vitamin A and synergistic formulations of vitamins C and E remain essential (e.g. Antioxidant ACE from Rationale, CE Ferulic from SkinCeuticals and C-Tetra Intense from Medik8). Immunoprotectants Vitamin B3 (niacinamide) Niacinamide is a key ingredient in cosmeceutical practice and, like vitamin A, is beginning to be hailed as another wonder vitamin in skincare due its wide-ranging effects. Topically, niacinamide includes benefits for ageing such as increased collagen and glycosaminoglycan production, acne with its anti-inflammatory effects, as well as demonstrating a reduction in sebum production and pore size, and dry skin by increasing the production of ceramides in the epidermis and pigmentation, through its effects on the melanin pathway.15 Gansara et al. also suggests that nicotinamide may influence telomere length through multiple mechanisms and have additional antiageing effects.16 In addition, emerging evidence shows that nicotinamide also acts as an adaptogen, with beneficial effects on sleep.17 However, the key action for niacinamide is that it is a powerful photo-immunoprotectant. UV irradiation depletes keratinocytes of cellular energy and niacinamide, which is a precursor of nicotinamide adenine dinucleotide (NADP) and niacinamide may act, at least in part, by providing energy repletion to irradiated cells.18 Relatively inexpensive with little toxicity, niacinamide has been shown to have powerful photoprotective effects against carcinogenesis and immune suppression in animals and is photo-immunoprotective in humans when used topically or orally. A formative study published in the New England Journal of Medicine by Professor Damian’s group confirmed in a randomised study that twice daily oral nicotinamide is effective in skin cancer chemoprevention.19 Resveratrol Resveratrol, a component in grape skin (and found in red wine), is a well-studied agent with a potential role in skin cancer chemoprevention, as well having other health benefits.20 Whilst resveratrol has come to the cosmeceutical skincare market mainly as a topical antageing (antioxidant) product, there is a growing body of evidence detailing its effects as an anticancer agent and recognition that it could play an important role in skin cancer management.21 Resveratrol suppresses metabolic activation of procarcinogens to carcinogens by modulating the metabolic enzymes

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responsible for their activation, and induces phase II enzymes, thus, further detoxifying the effect of procarcinogens. Furthermore, studies reveal that resveratrol also inhibits cell growth and induces cell death in cancer cells by targeting cell survival and cell death regulatory pathways. These effects are on top of its role in activating antioxidant enzymes and preventing inflammation.21 Polypodium leucotomos The phytochemical Polypodium leucotomos (PL or commercially known as Fernblock) is another immune photoprotectant that exhibits a number of benefits including inhibition of photo-immunosuppression, DNA photoprotection, anti-inflammatory effects, anti-skin cancer properties and remodelling of the dermal extracellular matrix.22 Importantly, it also inhibits the generation of reactive oxygen species (ROS) production induced by UV, including superoxide anion, and causes a marked decrease of UV-mediated cellular apoptosis and necrosis.22 It is a remarkable ingredient and has been incorporated into sunscreen preparations commercially (e.g. Heliocare). Cosmetic melanin Epidemiological data strongly support the photoprotective role of melanin in the skin as there exists an inverse correlation between skin pigmentation and the incidence of sun-induced skin cancers.23 It is not surprising, therefore, that researchers have tried to harness its power since Dr John Pawelek from Yale University patented the manufacture of synthetic melanin over 20 years ago. It has been used extensively in the cosmetics and biotechnology sectors and integrated as an important skin conditioning agent and component within sunscreens.24 In Scientific American in 2017 there was an interesting article reporting early results from synthetic nanoparticle melanosomes. Not only were the melanin-like nanoparticles transported and distributed throughout skin cells like natural melanin – they also protected the cells’ DNA. The researchers incubated skin cells with nanoparticles and then exposed them to UV radiation. After three days, 50% of the skin cells that absorbed the nanoparticles survived, compared with just 10% of those without nanoparticles, highlighting the photoprotective effects of nanoparticle synthetic melanin.25 Vitamin D3 On a bigger picture, vitamin D is essential for immune system health but we also know that optimum vitamin D3 levels are associated with protection against a number of malignancies; a strong body of evidence from animal and cell culture studies supports this protective role. However, evidence also indicates that vitamin D signalling protects the skin from cancer formation by controlling keratinocyte proliferation and differentiation, facilitating DNA repair, and suppressing activation of the hedgehog (Hh) pathway following UVR exposure. Many skin specialists therefore recommend regular use of oral vitamin D3 supplements for photoimmune protection.26,27,28 Solar protective botanicals and adaptogens Many of the exciting and powerful ingredients now used in cosmetic skin science have a botanical origin, which has prompted researchers to look even further into the photoprotective benefits of compounds within the plant and marine worlds.29 In a post-COVID world there is also a profound and resurgent desire to use ‘natural’ ingredients wherever possible and boost the body’s (skin) immunity. Of note, extremophile plants have garnered much attention. Scientists have studied extracts from extremophile plants which are those that live and operate in the most challenging environments,

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Within the last five years especially there has been an explosion in advancements sunscreen technologies and in the whole concept of photoprotection including the extreme heat and droughts in deserts, as well as those dominated by the extreme cold in Antarctica, or indeed in the salinity of the oceans.30 Australian SolarProtective Botanicals used by Rationale, Alpine Botanicals used by Albus and Flora and Desert Resurrection Plants by Hydraskin are just several examples of this. In a similar vein, so-called adaptogens are also being incorporated into photoprotective strategies. An adaptogen is essentially a botanical that adapts to your body’s needs by reducing the effects of stress on the body – including inflammation (from UV exposure).31 These adaptogenic ingredients have been used for centuries in eastern modalities such as Chinese traditional medicine and Ayurvedic medicine and may be used topically or orally. Ashwagandha, a particularly well-known adaptogen, is a herb that aims to alleviate many of the symptoms of a stressful modern life. It also contains potent antioxidant properties that help protect the skin against free radical damage and ageing.32 Schisandra (a medicinal berry) is another type of adaptogen which has multiple healing properties and small studies suggest it has photoprotective and environmental benefits for the skin. In Ayurvedic medicine, triphala is known as ‘three fruits’ and is made from the combination of three myrobalans, fruit-bearing trees: amalaki, bibhitaki and haritaki. In particular, amalaki is being investigated for its antioxidant properties and is said to contain 20 times the vitamin C of an orange, which is essential for collagen synthesis. Triphala can also be applied topically to aid in the healing of bruises and sunburn.33 The role of diet and nutraceuticals for skin health is a huge subject and outside the scope of this article, but these also offer other approaches to suppression of phototoxic responses. Whilst we know marine collagen should be part of a daily skin health regime, we also now know that biomarine extracts can significantly protect the skin from ultraviolet A-induced sun damage.34

Conclusion The concept of photoprotection for ageing well and optimal skin health is now firmly entrenched in the aesthetics specialty. Recent innovations with superfluids, novel antoxidants and emerging botanicals with extremophile and adaptogenic properties provide more options to help educate patients and practitioners alike. Robust photoprotection skin regimes should form an essential part of our recommendations to patients to age well, alongside their other injectable and skin treatments.

Mr Paul Banwell is a consultant plastic surgeon and the Director of The Banwell Clinic in East Grinstead and London. He has published more than 100 papers, manuscripts and books, and was the founder and former head of The Melanoma and Skin Cancer Unit (MASCU) in East Grinstead. He is also a visiting professor at Harvard Medical School and lectures globally on skin cancer, cosmeceutical skincare, scars as well as cosmetic surgery topics. Qual: BSc (Hons) MB BS FRCS(Eng) FRCS(Plast) REFERENCES 1. Hughes MC, Williams GM, Baker P, Green AC. Sunscreen and prevention of skin aging: a randomized trial. Ann Intern Med. 2013 4;158(11):781-90. 2. Freitas JV, Junqueira HC, Martins WK, Baptista MS, Gaspar LR. Antioxidant Role on the Protection of Melanocytes Against Visible Light-Induced Photodamage. Free Radic Biol Med 2019; 131: 399-407. 3. McDaniel D, Farris P, Valacchi G. Atmospheric Skin aging-Contributors and Inhibitors. J Cosmet Dermatol. 2018 Apr;17(2):124-137. 4. Young AR, Claveau J, Rossi AB. Ultraviolet Radiation and the Skin: Photobiology and Sunscreen Photoprotection. J Am Acad Dermatol. 2017; 76(3S1): S100-S109. 5. Gibbs NK, Norval M. Photoimmunosuppression: A Brief Overview. Photodermatol Photoimmunol Photomed. 2013; 29(2): 57-64. 6. Halliday GM. Inflammation, Gene Mutation and Photoimmunosuppression in Response to UVRinduced Oxidative Damage Contributes to Photocarcinogenesis. Mutat Res. 2005; 571(1-2): 107-20. 7. Maier T, Korting HC. Sunscreens - Which and What For? Skin Pharmacol Physiol. 2005; 18(6):253-62. 8. Diffey BL, Grice J. The Influence of Sunscreen Type on Photoprotection. Br J Dermatol. 1997; 137(1):103-5. 9. Mancuso JB, Maruthi R, Wang SQ, Lim HW. Sunscreens: An Update. Am J Clin Dermatol. 2017;18(5):643-650. 10. SE Cross, B Innes, MS Roberts, T Tsuzuki, TA Robertson, P McCormick. Human Skin Penetration of Sunscreen Nanoparticles: In-vitro Assessment of a Novel Micronized Zinc Oxide Formulation. Skin Pharmacol Physiol 2007; 20: 148–154. 11. Graf J. Antioxidants and skin care: the essentials. Plast Reconstr Surg 2009: 125(1):378. 12. Nakamura T, Pinnell SR, Streilein JW. Antioxidants can reverse the deleterious effects of ultraviolet (UVB) radiation on cutaneous immunity. J Invest Dermatol. 1995; 10 (4): 600. 13. Masaki HJ. Role of Antioxidants in the Skin: Anti-Aging Effects. Dermatol Sci. 2010; 58(2):85-90. 14. T. Herrling, K. Jung, J. Fuchs. UV - Generated Free Radicals (FR) in Skin and Hair –Their Formation, Action, Elimination and Prevention. SOWF Journal 2007; 133(8): 1-11. 15. DS Berson , R Osborne , JE Oblong , T Hakozaki , MB Johnson , DL Bissett. Niacinamide: A Topical Vitamin with Wide-Ranging Skin Appearance Benefits.. Cosmeceuticals and Cosmetic Practice, First Edition. Chapter 10 103-112. Ed. Patricia K. Farris. 2014 John Wiley & Sons, Ltd. 16. Gansara K, Gupta SS. DNA Damage, Repair and maintenance of telomere length: Role of Nutritional supplements. Mutagenicity: Assays and Applications Chapter 14. 2018: 287-307. 17. Gulati K, Anand R, Ray R. Nutraceuticals: efficacy, safety and toxicity 2016 p 193-205 18. D Surjana, GM. Halliday, DL. Damian. Role of Nicotinamide in DNA Damage, Mutagenesis, and DNA Repair. J Nucleic Acids. 2010; 2010: 157591. 19. AC. Chen, AJ. Martin, B Choy, P Fernández-Peñas, RA. Dalziell, CA. McKenzie, RA. Scolyer, HM. Dhillon, JL. Vardy, A Kricker, G St. George, N Chinniah, GM. Halliday, DL. Damian. A Phase 3 Randomized Trial of Nicotinamide for Skin-Cancer Chemoprevention. N Engl J Med 2015; 373: 1618-26. 20. Shrotriya S, Agarwal R, Sclafani RA. A perspective on chemoprevention by resveratrol in head and neck squamous cell carcinoma. Adv Exp Med Biol. 2015;815:333-48. 21. Kostyuk VA, Potapovich AI, Lulli D, Stancato A, De Luca C, Pastore S, Korkina L. Modulation of human keratinocyte responses to solar UV by plant polyphenols as a basis for chemoprevention of nonmelanoma skin cancers. Curr Med Chem. 2013;20(7):869-79. 22. S Gonzalez, Y Gilaberte, N Philips, A Juarranz. Fernblock, a Nutriceutical with Photoprotective Properties and Potential Preventive Agent for Skin Photoaging and Photoinduced Skin Cancers. Int J Mol Sci. 2011; 12(12): 8466–8475. 23. M Brenner, V Hearing. The Protective Role of Melanin Against UV Damage in Human Skin. Photochemistry and Photobiology. 2009 PMCID: PMC2671032). 24. Pawelek JM, Körner AM. The Biosynthesis of Mammalian Melanin. Am Sci. 1982; 70(2):136-45. 25. N Gianneschi et al. Mimicking Melanosomes: Polydopamine Nanoparticles as Artificial Microparasols. ACS Central Sci 2017; 3(6): 564-569. 26. D Bikle. Protective actions of vitamin D in UVB induced skin cancer. Photochem Photobiol Sci. 2012 December; 11(12): 10.1039/c2pp25251a. 27. D Bikle, H Elalieh, J Welsh, D Oh, J Cleaver, A Teichert. Protective Role of Vitamin D Signaling in Skin Cancer Formation. J Steroid Biochem Mol Biol. 2013 July; 136: 271–279. 28. C Garland et al. The Role of Vitamin D in Cancer Prevention. Am J Public Health. 2006 February; 96(2): 252–261. 29. Allemann IB, Baumann L Botanicals in Skin Care Products. Int J Dermatol. 2009; 48(9):923-34. 30. Coker JA. Recent Advances in Understanding Extremophiles. F1000Res. 2019 Nov 13;8:F1000 Faculty Rev-1917. 31. Kaur P, Robin, Makanjuola VO, Arora R, Singh B, Arora S. Immunopotentiating Significance of Conventionally Used Plant Adaptogens as Modulators in Biochemical and Molecular Signalling Pathways in Cell Mediated Processes Biomed Pharmacother. 2017; 95: 1815-1829. 32. Mishra LC, Singh BB, Dagenais S. Scientific Basis for the Therapeutic Use of Withania Somnifera (Ashwagandha): A Review. Altern Med Rev. 2000; 5(4)334-46. 33. Peterson CT, Denniston K, Chopra D.J. Therapeutic Uses of Triphala in Ayurvedic Medicine. Altern Complement Med. 2017; 23(8):607-614. 34. Marotta F, Kumari A, Yadav H, Polimeni A, Soresi V, Lorenzetti A, Naito Y, Jain S.Biomarine extracts significantly protect from ultraviolet A-induced skin photoaging: an ex vivo study. Rejuvenation Res. 2012; 15(2): 157-60). 35. R Parker, New concepts in Photoprotection, CCR October, 2018. 36. Banwell PE., ‘Latest advances in photobiology: solar constant, IR & relevance for skin care regimes’, CCR, October 2017. 37. After Herrling T et al., ‘UV - Generated Free Radicals (FR) in Skin and Hair –Their Formation, Action, Elimination and Prevention’, A General View SOCF. 2007; 133(8): 2-11.

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Approaches to Eczema Management Dermatology nurse practitioner Emma Coleman shares her holistic approach to eczema management and presents a patient case study Approximately 15 million people in the UK are living with eczema.1 Also known as atopic dermatitis (AD) it is estimated that in 2015, GPs in England wrote 27 million prescriptions for topical AD treatments at a cost of approximately £169 million to the NHS.2 I have found that 4% of my entire patient base have eczema. The British Association of Dermatologists (BAD) acknowledges that the dermatology sector was under-provisioned in 2013,3 and in 2012, the BAD established the Psychodermatology Working Party to support this situation.4 The association also stated that 17% of dermatology patients need psychological support and 14% have a psychological condition exacerbating their skin disease.4 An integrated, holistic care approach to dermatology patients at the Royal London Hospital in 2015, led to 86% of dermatology subjects being discharged after one follow-up appointment, meaning the department had extra time for new referrals and the projected NHS cost savings were estimated at around £19,370 per year – up to £52,200 at five years.5 These figures suggest a need for change in approaches to eczema treatment in the UK, and here I present areas of research, both supporting and refuting unorthodox pathways. In my own clinic, I have observed that giving eczema patients and their families time, education and autonomy over the disease has a profound effect on disease attitudes. It should be noted that I don’t always charge for my time – treatment outcome is a priority for me.

Supplements Synbiotics AD may be associated with altered gut microbiata6 and three small scale trials provided evidence that mixed-strain bacterial supplement therapy (synbiotics), significantly improves the SCORAD Index in child subjects after eight weeks, possibly inducing immunological changes (n=39, 60 and 40 respectively).7-9 On the other hand, another trial (n=41), reported that there is no significant impact on SCORAD scoring with synbiotics, and cannot be viewed as effective therapy in AD cases.10

Omega 6 therapy Several studies have linked development of fatty, oversized liver in non-obese AD sufferers of all ages, thought to be due to abnormal lipid metabolism, possibly involving the enzyme delta-6-desaturase.11,12 It is thought that AD sufferers have a reduced rate of conversion of dietary linoleic acid into its metabolites, and impairment of incorporation of essential fatty acids (EFAs) into phospholipids, leading to elevated hepatic and reduced serum fatty acids.13 Additionally, an Italian study suggested that reduced foetal polyunsaturated fat (PUFA) blood levels may predict eczema development.14 As it appears that epidermal linoleic acid is depleted in AD sufferers, it follows that therapeutic fatty acid supplementation such as gamma linolenic acid (GLA), an omega 6 source, should improve symptoms.13 One double-blind trial demonstrated that taking oral evening primrose oil (EPO) reduces inflammation, dryness, scaling and severity compared to controls, with no adverse side effects.15 Another study provided evidence that when taken over a 12-week period, oral EPO significantly reduces the need to use topical steroids three-fold in adults and children compared to placebo.16 One study suggested that 6g of orally-administered EPO produced a rise of up to 46% in the epidermal dihomo-γ-linolenic acid (DGLA) levels, compared to a control group.17 Statistical support for using topical EPO

GPs in England wrote 27 million prescriptions for topical AD treatments at a cost of approximately £169 million to the NHS

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allergy testing; as stated in the NICE guidelines, impaired barrier function may lead to increased allergen susceptibility.41 The patient remarked that he was unlikely to stop smoking, but said that he would reduce alcohol and sugar intake. I advised a breathing/ meditation app for use at moments of stress, as well as the use of anti-histamines, which are known to alleviate itching in some eczema cases,42 emollients and a seven-day course of topical tacrolimus to calm the flare, as advised in the NICE guidelines stepped approach.42 I arranged for a follow-up and diet plan one week later. On December 9, the patient had not visited his GP about allergy testing. He explained he had been too busy with work, but when pushed he said he doesn’t like needles. I reiterated the importance of this and suggested his mum go with him to the appointment. Patient compliance is a common issue that I encounter and is difficult to manage at times, which is why frequent contact is essential. Although, the patient’s redness, itching and excoriation had significantly calmed and his POEM score had reduced to from 14 to 9 (moderate eczema). He had purchased and started taking the supplements – synbiotics three times daily and EPO once daily – which take an average of eight weeks to start working, in my experience. The patient had undertaken short mediation sessions three times over the last week via an app called ‘Head Space’ and his mood seemed elevated. I asked why this was and he said, “I feel positive that I’m trying a different approach.” I commenced him on a course of 1% topical hydrocortisone and provided him with dietary 0-2 Clear or almost clear recipes, involving reduced sugar and saturated fat options, daily 3-7 Mild eczema celery juices and increased fruit and vegetables. We arranged 8-16 Moderate eczema for a phone call follow up at two weeks, and another face-to-face consultation at four weeks. 17-24 Severe eczema We had the phone call on December 23, and I advised him to stop 25-28 Very severe eczema using 1% topical hydrocortisone, based on his reporting of further Figure 1: Patient-Orientated Eczema Measure (POEM) score scale. improvement to his skin condition including reduced redness and Scores are calculated based on the results of seven questions relating itching. This part of the treatment was stopped to prevent risk of to the patient’s experience with their eczema. The POEM scale is freely available to use and can be downloaded from The University of skin atrophy, and to allow the other lifestyle changes to do their part Nottingham.40 in preventing the eczema. This was explained to the patient. On I explained my plan to calm the eczema flare then treat the January 8, the patient came back to clinic for his scheduled face-toacne, because the former was causing the most discomfort and face consultation. He still had not visited his GP regarding general topical acne treatments are designed to aggressively dry out blood and allergy tests, reporting he needed to arrange a date affected skin. My initial plan was to commence synbiotic and EPO with his mum. I explained the importance of this again, suggesting therapy, and refer the patient to his GP for full blood count and that all his hard work would be in vein if he doesn’t have the tests. I provided details of a private clinic in London, which Before Before he may prefer. The patient has continued to comply with the supplements and meditation; his mum has agreed to prepare the types of meals I have recommended for him to eat. On assessment, his POEM score was 0, however the patient was very agitated about his acne and we turned our attention to treatment of this aspect, for which I was able to After After prescribe Skinoren (azelaic acid) and create a new holistic plan, with which we have had some success. There is never a quick fix for healing skin conditions like eczema, and I am committed to exploring triggers with patients to get to the root cause. I feel the success of this eczema management case was Figure 2: Patient presenting to clinic with symptoms of eczema on December 2, 2019, partly attributed to regular patient contact, including and following my treatment plan on December 23. As the images were taken several emotional support and encouragement, alongside weeks apart, there is an evident lighting contrast in the before and after images. However, I believe the improvement in the patient’s skin can be observed. the holistic treatment programme itself.

Patient case study

A 21-one-year old man presented to me on December 2 2019 with poorly demarcated redness to the face with frequent itching and visible excoriation. He had a history of itching, inflamed rash to the face and sometimes the upper arms for the past two years, with prior history of flare ups since early childhood, (from the age of approximately one year). The patient had known allergies to erythromycin and penicillin, hay fever, and was using Dermol cream and Betamethasone Valerate 0.1% from the GP at his initial consultation. I diagnosed moderate eczema based on a Patient-Orientated Eczema Measure (POEM) score of 14.40 I also performed my Five Pillars Consultation, assessing lifestyle and psychological status. In addition, I identified that the patient also has acne vulgaris (mild) over his lateral lower face. In the consultation he explained that the eczema was disturbing his sleep and impacting his social life due to feelings of selfconsciousness. He works for his dad at a transportation company operating at management level, which he finds stressful. He feels the impact of stress in his stomach, experiencing nausea at times. He lives with his parents, smokes an average of 10 cigarettes daily and drinks beer at weekends. He is a grazer, snacking on fizzy drinks, crisps and sandwiches during the day; his mum prepares his evening meals – usually meat, potatoes or pasta and vegetables, rarely fish. In this case, the two-way relationship between AD, mental and physical health was clear.

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Use of complementary and alternative medicine and psychological interventions in alleviating eczema and its symptoms remains controversial is limited, with only one small-scale trial showing positive outcome when using this therapy with eczema patients.18 In all cases, study sizes are small and steroids are often used alongside EPO; one study refutes the benefits of EPO in AD, highlighting a need for further trials.20 Sea buckthorn There is evidence to suggest supplementation with 10g of sea buckthorn pulp over four months led to reduced AD symptoms, improved skin condition and elevated serum high density lipoprotein cholesterol levels (n=49).19

Psychological and complementary therapies We often associate stress as a cause of inflammatory disease flares; this has been extensively studied with AD cases and some findings are interesting. One investigation found no significant elevation of basal serum cortisol or adrenocorticotropic hormone (ACTH) levels in eczema patients compared to a non-AD population.21 Eczema patients appear to have sparse numbers of adrenergic β-adrenergic receptors compared to non-AD patients, causing a blunted hypothalamic-pituitary-axis (HPA) response.22 Animals that fail to generate a sufficient glucocorticoid response to pharmacological or psychological stimuli are highly vulnerable to inflammatory processes.23,24 In one study, 20% of eczema patients report anxiety and 14% depression, which tend to increase in correlation with symptom severity.25 Use of complementary and alternative medicine (CAM) and psychological interventions in alleviating eczema and its symptoms remains controversial at present. Several studies highlight a positive correlation between CAM, stress relief and improved quality of life in eczema

sufferers.26-31 However, trials have often been identified as haphazard in their randomisation methods and outcome measurement, and too small scale to warrant real value.32 One study combined therapeutic autogenic training and cognitive behavioural therapy in eczema patients, which led to reduced topical steroid use and skin condition improvement.27 Whilst there is evidence to suggest that combining group and relaxation therapies reduced scratching in 100% of AD subjects (n=10),26 application of ayurvedic herb Nigella sativa was comparable to betamethasone in its reduction of hand eczema over a four-week period, leading to significant Dermatology Life Quality Index (DLQI) score reduction.29 Elevated epinephrine and norepinephrine concentrations in eczema patients were significantly reduced by four weeks of treatment with EPO compared to control in a German study.31 There is evidence to suggest that autogenic training, cognitive behavioural therapy, combined dermatological education and cognitive-behavioural therapy, as well as habit reversal behavioural therapy, significantly reduce itch and scratching intensity.27,33,34 In summary, the evidence is promising but needs wider attention.

Diet

between dietary habits and clinical status were highlighted.36 Another longitudinal study (n=1,265) conducted over 10 years found that infants weaned onto solid food by the age of four months were approximately 1.6 times more likely to develop childhood eczema, particularly in cases with family history of the disease.37 Fast foods, butter, margarine and pasta intake three or more times weekly may impact eczema incidence in children and adolescents according to one global, large scale study (n=500,827). Fruit, vegetables, eggs and milk consumption were inversely associated with severe current eczema and therefore labelled as protective. In the same study, there was no association identified between obesity and eczema.38 One individual case report provided strong evidence that eczema was lactose-induced in a male patient, where milk withdrawal led to complete resolution.39

Conclusion I see eczema treatment as three-fold â&#x20AC;&#x201C; symptom control, education and prevention â&#x20AC;&#x201C; and each patient is an individual and should be managed as such. There is a gap between eczema patient demand, dermatological resource and provision, and although evidence for taking a more holistic approach seems promising, and could be of value in long term management, future research including large scale studies is imperative. Emma Coleman is a dermatology and advanced aesthetic nurse practitioner with award-winning clinics in London and Kent. She trained in aesthetics in London in 2015 and gained a distinction in Clinical Dermatology Diploma with the University of South Wales in 2019. Coleman is a member of the British Dermatological Nursing Group (BDNG) and clinical director at the four Emma Coleman Skin clinics across Kent and London. Qual: RGN/DipDerm

My first step in creating an eczema patient plan is usually referral for blood and/or allergy testing. Dietary recommendations should be specific, given only in diagnosed individual food allergy,35 and dietary intervention remains controversial in this patient group. One study looked purely at dietary habits in AD and non-AD patients, and although vitamin D intake was lower in the AD group, there were no significant dietary differences between refined sugar or fruit and vegetable consumption, and no links

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Discoloration Defense: Expert Q&A with Dr Alexis Granite Breaking the cycle of discolouration with the new SkinCeuticals Discoloration Defense Serum Discoloration Defense Serum is a new multi-phase serum targeting visible discolouration and is clinically proven to deliver a brighter, more even skin tone. It is formulated to address visible pigmentation which can be triggered by inflammatory processes in the skin such as melasma caused by hormonal changes and blemish-scarring. Hero ingredient tranexamic acid minimises the

reoccurrence of discolouration and stubborn brown patches, thus breaking the cycle of discolouration with continued use. In a 12week study,1 twice-daily application of Discoloration Defense Serum demonstrated a statistically significant reduction in the appearance of post-inflammatory discolouration and uneven skin tone including 41% average reduction in the appearance of stubborn brown patches.

Table 1: Results of 12-week study of twice-daily application of Discoloration Defense Serum1

We asked Dr Alexis Granite, a consultant dermatologist practising at the Cadogan Clinic and Mallucci London, to explain how Discoloration Defense Serum helps improve the appearance of skin discolouration and promote exfoliation to reduce pigmentation.

1. What is skin discolouration and why do we get it? Skin discolouration may refer to either an excess of pigment (hyperpigmentation) or a lack of pigment (hypopigmentation). Generally speaking, discolouration products are targeted towards hyperpigmentation as this form is more amenable to treatment. Hyperpigmentation is caused by the overproduction of melanin within our skin and may be caused by a variety of factors including sun exposure, ageing, hormonal changes, inflammation or trauma to the skin. 52

2. What are the treatment options? There are a multitude of therapeutic options for hyperpigmentation including at-home skincare products, prescription topicals, and inclinic treatments such as chemical peels, microneedling and laser. Typically, when it comes to treating discolouration, a combination approach is most effective. When shopping for skincare to help combat discolouration ingredients to look for include vitamin C, niacinamide and retinol. There are a multitude of topical acids that may be used to treat hyperpigmentation such as tranexemic, azelaic, kojic and glycolic.

3. So how does Discoloration Defense Serum improve pigmentation? Why does it work? Discoloration Defense Serum works to improve the look of pigmentation by incorporating three key ingredients: 1.8% tranexamic acid, 5% niacinamide (a form of vitamin B3) and 5% HEPES. Both tranexamic acid and niacinamide target key types of discolouration. HEPES is derived from sulfonic acid and aids

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in epidermal skin cell turnover, helping to minimise the appearance of pigmentation and allowing other ingredients to penetrate more effectively. Continued use of Discoloration Defense Serum helps even skin tone and reduce the appearance of stubborn forms of discoloration.

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The regimen for using Discoloration Defense Serum at home Ideally three to five drops of Discoloration Defense Serum should be applied twice daily to the face. A sample regimen for skin discolouration and overall anti-ageing might include the following: AM:

4. What makes Discoloration Defense Serum different from other topical treatments for pigmentation?

1. Cleanse 2. Phloretin CF 3. Discoloration Defense Serum 4. Moisturiser/SPF

Discoloration Defense Serum is an optimised formula of anti-discolouration ingredients which work together to reduce the appearance of uneven skin tone and pigmentation. Its lightweight formulation makes it suitable for nearly all skin types and is easy to use.

PM: 1. Cleanse 2. Retinol on alternate nights as tolerated 3. Discoloration Defense Serum 4. Moisturiser

5. How do you use Discoloration Defense Serum in conjunction with other in-clinic treatments? Discoloration Defense Serum can be used in conjunction with other in-clinic treatments as well as prescription topical therapies such as hydroquinone. Typically, I recommend starting Discoloration Defense Serum once or twice daily two weeks prior to intense pulsed light (IPL) then continuing Discoloration Defense Serum for at least two weeks following the procedure as tolerated. I also use post-peel to sustain the benefits when all signs of irritation have disappeared and the skin has fully recovered.

Discoloration Defense Serum is an optimised formula of antidiscolouration ingredients which work together to reduce the appearance of uneven skin tone and pigmentation

6. Can it be used as a stand-alone treatment? Absolutely, especially for those with mild hyperpigmentation. Of course, the judicious use of sunscreen is also necessary in any skincare regimen when tackling discolouration. Once appearance of pigmentation has faded, it is best to continue with Discoloration Defense Serum to help continue targeting any potential discolouration.

7. Describe the ideal patient profile for treatment with Discoloration Defense Serum The ideal patient for treatment with Discoloration Defense Serum is someone with mild-moderate pigmentation of more recent onset. They may be looking for an at-home skincare product that complements a prescription topical treatment or in-clinic therapy for pigmentation.

8. How have your patients responded to Discoloration Defense Serum? My patients have been pleased with Discoloration Defense Serum. The majority have found the product easy to incorporate into their routine with its elegant, lightweight formulation. Most have reported improved skin brightness and more even skin tone. REFERENCES 1. DOF: A 12-week, single-centre, clinical study was conducted on 63 females, ages 26 to 60, Fitzpatrick I-IV, with mild to moderate facial pigmentation, including melasma, post-inflammatory hyperpigmentation and hyperpigmentation. Discoloration Defense Serum was applied to the face twice a day in conjunction with a sunscreen. Efficacy and tolerability evaluations were conducted at baseline and at weeks 2, 4, 8, and 12.

Contact: For more information about SkinCeuticals Discoloration Defense Serum: Email: contact@skinceuticals.co.uk Twitter: @SkinCeuticalsUK Instagram: skinceuticals_uki

Aesthetics | July 2020

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YOUR SKIN YOUR GLOW AHA Cleansing Gel PURIFIES, REVIVES, BRIGHTENS First essential step of every beauty routine


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non-inflammatory acne lesions, with good compliance.6 The study included 35 patients with mild-moderate acne and results showed that at 12 weeks both inflammatory and noninflammatory acne lesions had significantly decreased, by 77% and 54%, respectively. In another study, 28 healthy individuals with facial acne were treated with eight biweekly 15-minute sessions of high-intensity, narrowband blue light. Overall, there was a 64.7% improvement in acne lesions. No bacterial changes were noted, however damaged Propionibacterium acnes were observed at the ultrastructural level.7

Understanding the Impact of Blue Light on Skin Dr Aileen McPhillips discusses the impact of blue light on skin, the risks it presents and how practitioners should best advise patients With the evolution of the digital age and people spending more time than ever in front of screens, particularly in the past couple of months as a result of the COVID-19 lockdown, now more than ever is a good time to consider the effect of blue light on our patients’ skin. This article will explore the research behind blue light and its relevance to aesthetic practice.

What is blue light? Electromagnetic energy spans a broad spectrum from very long radio waves to very short gamma rays.1 Light is made up of electromagnetic particles that travel in waves.2 The human eye can only detect a small portion of this spectrum, which is called visible light.1 Blue light is a colour in the ‘visible light spectrum’ that can be seen by the human eye.2 It has a very short wavelength, and so produces a higher amount of energy than those of longer wavelengths.2 Blue light is everywhere. Sunlight is the main source of blue light,2 however there are now also many artificial sources of blue light, such as fluorescent lights, LED lights, flat screen LED TVs, computer screens, smart phones and tablet screens.3

Benefits of blue light Research has shown that exposure to some blue light is necessary for health and has many positive effects. It has a beneficial impact on the body by regulating the body’s circadian rhythm when subjected to exposure during the day, boosting alertness, improving memory and cognitive functions, and elevating mood.4 Blue light has been widely used in medicine for various treatments, such as in acne, psoriasis, atopic dermatitis, neonatal jaundice and wound healing, thanks to its antibacterial, antimicrobial and anti-inflammatory properties.5 Acne Research has shown that light therapy is a useful treatment in acne, without side effects or inconvenience to the patient. The results of a double-blind, randomised controlled trial showed that LED phototherapy was safe and effective for treating not only inflammatory, but also

Psoriasis In one study on the effect of blue light in psoriasis, 40 patients with mild-moderate psoriasis and bilateral plaques were assigned to two groups – group one received irradiation at home with blue light (LED 420 nm) once daily for four weeks, while group two used a different blue light device (LED 453 nm). The contralateral control plaques remained untreated in both groups. In total, 37 patients completed the trial and results showed significant improvement after four weeks in both groups of the irradiated plaques as per the ‘Local Psoriasis Severity Index’.8 Another study consisting of 20 patients compared treatment of psoriasis with blue light versus red light therapy. Two stable plaques were treated with either blue light or red light, three times weekly for four consecutive weeks. Both treatment options showed clinical improvement of psoriasis plaques, however erythema was more significantly improved following blue light treatment, therefore providing a more successful treatment.9 Atopic dermatitis Research has also suggested that blue light irradiation may be a potential treatment for atopic dermatitis. A study consisting of 36 patients with severe, chronic atopic dermatitis underwent one cycle of five consecutive blue light irradiations (28.9 J/cm2). The ‘Eczema Area and Severity Score’ (EASI) score was improved by 41% and 54% after three and six months, respectively. Significant improvement of pruritis, sleep and life quality was also noted, especially after six months.10 A further study of 21 patients has also indicated that blue light therapy was a safe and effective treatment for eczema. Areas treated with blue light three times per week for four weeks showed a statistically significant improvement in EASI score, with no adverse reactions reported.11

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Negative effects of blue light Whilst low doses of blue light may be beneficial for treating the skin conditions discussed above, high doses and long-term exposure can have negative consequences.12 Most people are aware of the dangers of UV exposure, however research has indicated that high energy visible (HEV) light generates similar amounts of reactive oxygen species (ROS) as UVA and UVB combined.4 As many of us spend numerous hours exposed to screens and overhead lights, the negative effects of these artificial sources of blue HEV is of increasing concern. The toxic effect of blue light on the skin has been shown to be related to the generation of non-enzymatic nitric oxide (NO) radicals.4 Blue light exposure can lead to inflammation, impaired healing, compromised melanogenesis, sensitivity, dryness, wrinkles, uneven tone and texture and sagging skin.4 The generation of free radicals in the skin resulting in oxidative stress contributes to photoageing.12 A study examining the effect of visible light on the ROS and matrix metalloproteinase (MMP) responses in the skin found that visible light can induce significant ROS production, and this ROS mediates the release of pro-inflammatory cytokines and MMP expressions. Activation of MMPs leads to breakdown of collagen and inhibits new collagen synthesis.13 Studies on human skin have shown that carotenoids are vital components of the antioxidative protective system of the human skin and could serve as marker substances for the overall antioxidative status.14 While there is very limited research in this area, a study of nine patients assessing the dose-dependent influence that blue-violet light can potentially exert of the antioxidant status of skin has been carried out.5 For the study, two areas were marked on the left and right forearms of volunteers. Blue-violet light irradiation was conducted by administrating 50K/cm2 on one forearm and subsequently 100K/cm2 on the other forearm. The right and left forearms were randomised from volunteer to volunteer. The carotenoid concentration was then measured using resonance Raman spectroscopy directly after, as well as at one, two and 24 hours after irradiation. The carotenoid destruction was noted to be twice as high at a dosage of 100J/cm2 compared to 50J/cm2. It also took a longer time to restore carotenoid levels to normal following irradiation at a higher dose – levels were restored one hour after 50J/cm2, compared to 24 hours following 100J/cm2.

As many of us spend numerous hours exposed to screens and overhead lights, the negative effects of these artificial sources of blue HEV is of increasing concern

The study indicated that higher irradiation doses give rise to the generation of a higher amount of reactive oxygen species and, therefore, to the depletion of a higher amount of carotenoids. Consequently, more time is required to restore the carotenoid level that existed prior to irradiation. Duteil et al. compared the effects of visible light with UVB exposure. They assessed the pro-pigmentating effects of two single wavelengths located at both extremities of the visible spectrum – blue/violet and red. Colorimetry, clinical and histological assessments were recorded with increasing doses of these lights on 12 healthy male volunteers, which were compared to nonexposed and UVB-exposed skin. Results showed, when compared to UVB-induced hyperpigmentation, blue-violet light induced a more pronounced pigmentation that lasted up to three months.15

Relevance to aesthetic practice The key to living safely with blue light is to find a healthy balance and protect the skin from unnecessary exposure. We should advise patients to use skincare products daily that protect our skin from blue light. This is significant, as most sunscreens do not provide protection against blue light/ visible radiation.10 HEV/blue light protection is different from SPF.4 Sunscreen Historically, sunscreens were developed with the focus of blocking UVB, with UVA protection being added when its immunosuppressive effect was noted.16 Research suggests that physical sunscreens, i.e. zinc oxide and titanium dioxide-containing sunscreens are superior at protecting the

skin from longer UVA rays and visible light than chemical sunscreens.17 This is due to their light-scattering properties which causes reflection of the light off the skin. Adding a visible light absorber such as iron oxide to scattering sunscreens substantially lowered transmittance of UV and visible light, therefore offering enhanced photoprotection.17 A double-blind randomised trial was conducted to assess the efficacy of sunscreen with broad-spectrum UV protection compared to a similar product with the addition of iron oxide.18 It involved 68 patients who were being treated with 4% hydroxyquinone for melasma. Two groups were randomly assigned one of two sunscreens – a standard broadspectrum SPF 50 or a similar sunscreen with iron oxide added. The patients were assessed using the Melasma Activity and Severity Index (MASI), colorimetry and histological analysis of melanin at the onset and conclusion of the study. Over an eight-week period all patients experienced reduction in hyperpigmentation, however those who used the sunscreens with addition of iron oxide experienced significantly better results – 15%, 28% and 4% greater improvements in end points, respectively. Antioxidants It is thought that visible/blue light accounts for 33% of free radical production in the stratum corneum, which is the primary factor in skin damage.12 Although this is much less than that of UV radiation, it demonstrates the damaging effects it can have on skin. Antioxidants can neutralise the free radicals produced by UV radiation and visible light.19 They can also reduce the number of free radicals produced in the first place.19

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


Research has been carried out to determine whether antioxidants can reduce the damage caused by visible light compared to the use of UVA/UVB sunscreen alone and the same sunscreen combined with antioxidants. Results showed that the combined UVA/UVB sunscreen with antioxidants reduced reactive oxygen species (ROS) by 78%, therefore demonstrating the benefit of using antioxidant protection.13

Conclusion Advising patients to wear broad spectrum sunscreen daily should be top of our list in all skin consultations. Many people think sunscreen is only necessary when going outdoors, however we now know it is important even when indoors due to the many artificial sources of potential skin damage. We should also consider blue light filters for digital devices and limiting screen time exposure, especially at night time. Dr Aileen McPhillips is a medical graduate of Queen’s University, Belfast and currently works as a GP and aesthetic practitioner, running her own clinic ‘Aesthetics by Dr Aileen - The Skin Health Clinic’ based in Aughnacloy, Co. Tyrone. She is a member of the Royal College of General Practitioners and has completed a Level 7 certificate in Injectables for Aesthetic Medicine. Dr McPhillips enjoys all aspects of aesthetic practice, although has a keen interest in maintaining skin health and skin rejuvenation. Qual: MB, BCh, BAO, MRCGP, DRCOG REFERENCES 1. NASA, Introduction to the Electromagnetic Spectrum <https://science.nasa.gov/ems/01_intro> 2. Blue Light Exposed, Shine the Light on Blue Light <http://www.bluelightexposed. com/#bluelightexposed> 3. Prevent Blindess, Your Sight: Protect Your Eyes from the Sun <www.preventblindness.org/bluelight-and-your-eyes/> 4. Dermascope, Fact or Fiction: skin damage caused by HEV light may be as harmful as the damage caused by UVA and UVB light combined <www.dermascope.com/fact-or-fiction/skindamage-caused-by-hev-light> 5. Vandersee S, Beyer M, Darvin ME., ‘Blue-Violet Light Irradiation Dose Dependently Decreases Carotenoids in Human Skin Which Indicated the Generation of Free Radicals’, Oxidative Medicine and Cellular Longevity 2015; 2015:579675. 6. Kwon HH, Lee JB et al., ‘The Clinical and Histological Effect of Home-Use Combination BlueRed LED Phototherapy for Mild-Moderate Acne Vulgaris in Korean Patients: A Double-Blind, Randomised Controlled Trial’, British Journal of Dermatology, 2013 May; 186(5):1088-94. 7. Omi T, Bjerring P, Sato S, Kawana S, Hankins RW, Honda M. ‘420Nm Intense Continuous Light Therapy for Acne’. Journal of Cosmetic and Laser Therapy 2004; 6(3):156-162. 8. Weinstabl A, Hoff-Lesch S, Merk HF, vonFelbert V., ‘Prospective Randomised Study on the Efficacy of Blue-Light in the Treatment of Psoriasis Vulgaris’. Dermatology, 2011; 223(3):251-9. 9. Kleinpenning MM, Otero ME, van Erp PEJ, Gerritsen MJP, van de Kerkhof PCM. ‘Efficacy of Blue Light vs Red Light in the Treatment of Psoriasis: A double-blind, randomised Comparative Study.’ Journal of the European Academy of Dermatology and Venereology 2012 Feb; 26(2):219-225. 10. Keeps K, Pfaff SC, Born M, Liebmann J, Merk HF, vonFelbert V. ‘Prospective, Randomised Study on the Efficacy and Safety of Local UV-Free Blue Light Treatment of Eczema’. Dermatology 2016; 232(4):496-502. 11. Becker D, Langer E, Seemann M, Seemann G, Fell I, Saloga J, Grabbe S, von Stebut., ‘Clincal Efficacy of Blue Light Full Body Irradiation as Treatment Option for Severe Atopic Dermatitis’, PLoS One 2011; 6(6):e20566. 12. Bernstein EF, Sarkas HW, Bouche D., ‘Beyond Sun Protection Factor: An Approach to Environmental Protection with Novel Mineral Coatings in a Vehicle Containing a blend of Skincare Ingredients’, Journal of Cosmetic Dermatology, 2020 Feb; 19(2): 407-415. 13. Liebel F, Kaur S, Ruvolo E, Kollits N, Southall MD., ‘Irradiation of Skin with Visible Light Induces Reactive Oxygen Species and Matrix-Degrading Enzymes’, Journal of Investigative Dermatology, 2012; 132(7): 1901-1907. 14. Darvin MA, Sterry W, Vergou T., ‘The Role of Carotenoids in Human Skin’, Molecules 2011 Dec; 16(12): 10491-10506. 15. Duteil L, Cardot-Leccia N, Queille-Roussel C, Maubert Y, Harmelin Y, Boukari F, Ambrosetti D, Lacour JP, Passeron T., ‘Differences in Visible Light-Induced Pigmentation According to Wavelengths: A Clinical and Histological Study in Comparison with UVB Exposure’, Pigment Cell Melanoma Res, 2014; 27:822-826. 16. Moyal DD, Fourtanier AM., ‘Broadspectrum Sunscreens provide better protection from Solar Ultraviolet-Stimulated Radiation and Natural Sunlight-Induced Immunosuppression in Human Beings’, Journal of American Academy of Dermatology, 2008; 58(5):S149-154. 17. Kaye E, Levin J, Blank I, Kenneth AA, Rox Anderson R., ‘Efficiency of Opaque Photoprotective Agents in the Visible Light Range’, Arch Dermatology, 1991; 127(3):351-355. 18. Castanedo-Cazares JP, Hernandez-Blanco D, Carlos-Ortego B, Fuentes-Ahumada C, TorresAlvarez B., ‘Near-Visible Light and UV Photoprotection in the Treatment of Melasma: a doubleblind randomised trial’, Photodermatology, Photoimmunology and Photomedicine, 2013; 30(1): 35-42. 19. Science Becomes Her, Should I wear sunscreen indoors? <www.sciencebecomesher.com/ should-I-wear-sunscreen-indoors/>

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nervous system, regulating memory, mood, sleep, appetite, and pain sensation.3 CB1 receptors are present in a range of peripheral tissues as well. The neuropsychological effects of many cannabinoids are thought to work via their actions on CB1 receptors. CB2 receptors, in contrast, have been coined the â&#x20AC;&#x2DC;immunomodulatory cannabinoid receptorsâ&#x20AC;&#x2122;, mediating anti-inflammatory effects in peripheral tissues.10 Both CB1 and CB2 receptors are present on cutaneous sensory nerve fibres, mast cells, and keratinocytes, making them a prime target for dermatological research.11 However, further studies into cannabinoids have demonstrated a much more complex physiological profile than these two receptors alone. Cannabinoids can impact on a range of other GPCRs, transient receptor potential channels, and peroxisome proliferator activated receptors.12 Mice models with knockouts of both CB1 and CB2 receptors show cannabinoids can still exert potent immunomodulatory effects, highlighting the need for further research into this area.13 Cannabinoids have proven clinical efficacy in the treatment of a number of different Dr David Gleeson and Dr Sandeep Cliff discuss the conditions, ranging from neurological such as epilepsy and spasticity, to evidence behind CBD-based skincare products; the conditions psychological conditions such as anxiety and new hot topic in dermatology anorexia.1,3,14 With regards to skin conditions, active research is currently ongoing; There has been an explosion of interest in recent years in the looking into the role of cannabinoids in the treatment of inflammatory use of cannabinoid-based products. Cannabinoids (CBDs) are a conditions such as psoriasis and acne, through to their potential antidiverse range of compounds that have been shown to be effective tumour effects in the treatment of melanomas.1 in the treatment of a range of different medical conditions, such as intractable epilepsy, chronic pain, asthma, and mood disorders.1,2,3,4 Acne In vitro studies identified anti-inflammatory properties of these The underlying pathophysiology of acne is complex, driven by a compounds, paving the way for research into the potential use of strong inflammatory component, combined with the interplay topical CBD-based products in dermatology.5,6,7 However, whilst between hormones, the immune system, infections, and the there are already many creams and ointments available on the environment.15 Cannabinoids have been shown to exert antimarket, the evidence to support their usage is currently limited, and inflammatory effects within the skin microenvironment, and there is our understanding of the underlying physiology is still very much in a lot of interest in the potential use of topical CBD-based products its infancy. for the treatment of acne. Sebocytes, the sebum-producing epithelial cells found within the hair follicle complex and sebaceous Background glands, express CB2 receptors.16 Primary research has shown CB2 Cannabinoids are a diverse class of active compounds that react agonists and antagonists exert varied effects on lipid production with cannabinoid receptors and are divided into three main and sebocyte apoptosis. Whilst some compounds reduce lipid classes.8 Endocannabinoids are naturally-occurring compounds synthesis, and hence reduce acne flares, other compounds drive found in humans and animals. Phytocannabinoids are plant-derived increased sebum production.17 Many phytocannabinoids, for compounds, with delta-(9)-tetrahydrocannabinol (THC), the main example, stimulate sebum production, with acne noted to be a active ingredient in cannabis, being the most well-known. Synthetic common side effect of excessive cannabis smoking.18 There is now cannabinoids, produced in laboratories, are a separate class that can preliminary trial evidence supporting the use of CBD-based products be further subdivided into six different groups.9 With more than 110 in the treatment of acne. A single-blinded 12-week trial looked at the identified cannabinoids, this is a complex chemical family, with a wide effects of 3% cannabis seed extract cream on sebum production and range of physiological properties. erythema.19 There was a significant reduction in both measures in the test cohort, and the cream was well-tolerated. However, the trial was Physiology small, comprising only 11 test subjects, all of whom were male. Larger, Cannabinoids exert their effects primarily through two G-protein double-blinded, randomised controlled trials with a representative coupled receptors (GPCRs), CB1 and CB2.1,3 CB1 receptors are testing cohort are required to fully investigate the potential use of predominantly distributed throughout the central and peripheral cannabinoid-based therapies in the treatment of acne.

Exploring CBD as a Skincare Ingredient

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Eczema Atopic eczema is a chronic, relapsing-remitting inflammatory disease of the skin, characterised by dry itchy eczematous lesions. It is highly prevalent, affecting between 15-30% of children, and 1-2% of adults.20,21 Primary research has shown the topical THC application decreased the production of the inflammatory cytokines CCL2 and IFN-γ by keratinocytes and T cells, highlighting the potential of cannabinoid products to alter the inflammatory milieu in eczema.22 Robust trial evidence is again lacking, but promising initial research studies have been published on this matter. One study looking into atopic dermatitis in a paediatric population showed that twice daily application of the endocannabinoid Palmitoylethanolamide (PEA), for four to six weeks, produced statistically significant reductions in disease severity and patient-reported pruritus.23 A large, prospective cohort study involving 2,456 patients also looked into the use of a PEA-containing emollient cream over a period of four to six weeks.24 Again, there was a statistically significant improvement in patientreported symptoms, decreased use of topical steroids, decreased loss of sleep-related to itching, and a clinical improvement in the degree of erythema, dryness and excoriations. Asteatotic eczema is a common dermatitis manifesting as extremely dry skin, often affecting the elderly. It presents with a distinctive ‘crazy-paving’ appearance, which is predominantly on the shins. A randomised, controlled trial of 60 patients was carried out looking into the therapeutic potential of PEA and N-acetylethanol-amine (NEA) twice a day for 28 days.25 Both creams were superior in improving skin scaling, dryness, and itching over the period than a control emollient. No treatments are currently licensed, but the field is promising, and further large-scale trials will hopefully prove the benefits of cannabinoid therapies in the treatment of eczema.

Cannabinoids have been shown to exert antiinflammatory effects within the skin microenvironment, and there is a lot of interest in the potential use of topical CBD-based products for the treatment of acne Initial laboratory work has sparked interest; the application of PEA was shown to reduce histamine secretion in animal models, reducing the sensation of itch.30 However, whilst there has been lots of potential shown, we are yet to see any benefit in larger clinical trials. A singleblinded comparison study of 100 patients, assessing the effect of a PEA-containing lotion, did not result in any significant difference in pruritus intensity, quality of life or the cosmetic appearance of dry skin when compared to a control lotion.31 Translating promising primary research results into deliverable clinical benefit appears to be an ongoing issue for cannabinoids in dermatology.

Psoriasis Psoriasis is a chronic inflammatory skin condition, manifesting as clearly defined, red and scaly plaques, which is divided into several subtypes. Abnormally excessive and rapid cell keratinocyte turnover is driven by an inflammatory cascade within the dermis, involving the innate and adaptive immune systems.26 TNF-α, IL-1β, IL-6 and IL-22 all play a key role in stimulating keratinocyte proliferation. Preliminary laboratory-based research has shown cannabinoids can reduce keratinocyte proliferation in psoriasis animal models, but the mechanism is still very unclear at present.27 Cannabinoids trigger the conversion of a Th1-predominant cell profile to a Th2-predominant profile, mediating a shift towards immunosuppression, and thereby breaking the cycle of inflammation and proliferation.28 However, these effects do not appear to be mediated via CB1 and CB2 receptors, but rather via the PPARγ pathway.28 Whilst the first products are being generated for trials at present, it is likely that we are still some way off having sufficient understanding to generate effective treatment options for psoriasis.

Pruritus Pruritus, the unpleasant sensation of the skin provoking the urge to scratch, is a characteristic feature of many dermatological conditions, and some systemic diseases. Given their distribution on key cells within the skin, it is hoped that CB1 and CB2 receptors may be effective therapeutic targets for the management of this debilitating symptom. CB1 and CB2 agonists reduce itch stimuli via the stimulation of inhibitory receptors on cutaneous sensory nerves, mast cells, and keratinocytes.29

Side effects The side effects of the systemic use of cannabinoids are well documented. Synthetic compounds in particular have been linked with anxiety, confusion, agitation, changes in mood, psychosis, nausea, diaphoresis, rhabdomyolysis, and acute kidney injury, amongst others.32 Excessive smoking of cannabis has been linked to periorbital darkening, hallowed-cheeks, premature ageing, hair loss, greying of hair, and acne.18 It is currently unclear what the side-effect profile of topical CBD-based products is. Allergy and cross-sensitisation to other products are a worry, and the most commonly reported side effects are dry skin, urticarial and pruritus.33 However, these were incidental reports, and the majority of topical CBD-based trials appear to report good tolerability. The role of cannabinoids in malignancy is currently very unclear. Both melanoma and non-melanoma skin cancers express CB1 and CB2 receptors. Cannabinoids have been shown to elicit pro-apoptotic and anti-proliferative effects in prostate, gastro-intestinal, and breast carcinoma studies, via various different mechanisms.34 THC has also been shown to trigger autophagy-dependent apoptosis in melanoma mouse models.1 However, in a different study, CB1 activation was also shown to trigger proliferation of melanoma cells in vitro.35 THC has also been shown to amplify the expression of Kaposi sarcoma-associated herpes virus, leading to the proliferation of endothelial cells and the appearance of Kaposi sarcoma in vitro.36 The potential pro-tumour impacts of cannabinoid therapy is an essential area of research that requires further investigation before these products can be used on a wider scale clinically.

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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Conclusion There is widespread interest in the potential of CBD-based skincare products within dermatology at the moment. Whilst there have been many promising results from primary research with animal models and in vitro studies, we are yet to see large-scale, robust clinical trials proving the efficacy of cannabinoids for the treatment of dermatological conditions. Furthermore, the side-effect profile of these products, especially their impact on neoplastic development, needs further elucidation. Dr David Gleeson is an internal medicine trainee at East Surrey Hospital. He trained at Oxford University before completing foundation training in London. He has a keen interest in dermatology and teaching, and has previously worked as a dermatology clinical teaching Fellow at Imperial College London. Qual: BA(Hons), BM BCh, MRCP, PGCert (MedEd) Dr Sandeep Cliff is a consultant dermatologist at a university hospital and has a particular interest in skin cancer and inflammatory dermatosis. He has lectured and demonstrated extensively throughout the world on various non-invasive techniques for facial rejuvenation, including lasers, dermal fillers and toxins. He has been principal investigator for over six clinical research trials and is a clinical sub-dean at Brighton and Sussex Medical School. Qual: FRCP BSc REFERENCES 1. Armstrong JL, Hill DS, KcKee CS, et al. “Exploiting cannabinoid-induced cytotoxic autophagy to drive melanoma cell death.” JInvest Dermatol (2015): 135(6):1629-1637. 2. Basu S, Dittel BN. “Unraveling the complexities of cannabinoid receptor 2 (CB2) immune regulation in health and disease.” Immunol Res. (2011): 51(1):26-38. 3. Sarfaraz S, Adhami VM, Syed DN, Afaq F, Mukhtar H. “Cannabinoids for cancer treatment:Progress and promise.” Cancer Res (2008): 68(2):339-342. 4. Pisnti S, Bifulco M. “Endocannabinoid system modulation in cancer biology and therapy.” Pharmacol Res (2009): 60(2):107-116. 5. Nikan M, Nabavi SM, Manayi A. “Ligands for cannabinoid receptors, promising anticancer agents.” Life Sci (2016): 146:124-130. 6. Zgair A, Lee JB, Wong JCM, et al. “Oral administration of cannabis with lipids leads to high levels of cannabinoids in the intestinal lymphatic system and prominent immunomodulation.” Sci Rep. (2017): 7(1):14542. 7. Niaz K, Khan F, Maqbool F, Momtaz S, Ismail Hassan F, Nobakht-Haghighi N, Rahimifard M, Abdollahi M. “Endo-cannabinoids system and the toxicity of cannabinoids with a biotechnological approach.” EXCLI J. (2017): 16:688-711. 8. Lu HC, Mackie K. “An Introduction to the Endogenous Cannabinoid System.” Biol Psychiatry (2016): 79(7):516-25. 9. Diao X, Huestis MA. “New Synthetic Cannabinoids Metabolism and Strategies to Best Identify Optimal Marker Metabolites.” Front Chem. (2019): 7:109. 10. Kupczyk P, Reich A, Szeptietowski J. “Cannabinoid system in the skin - a possible target for future therapies in dermatology.” Exp Dermatol (2009): 669-679. 11. Ständer S, Luger TA. “Itch in atopic dermatitis - pathophysiology and treatment.” Acta Dermatovenerol Croat (2010): 18(4):289-296. 12. De Petrocellis L, Di Marzo V. “Non-CB1, non-CB2 receptors for endocannabinoids, plant cannabinoids, and synthetic cannabimimetics: focus on G-protein-coupled receptors and transient receptor potential channels.” J Neuroimmune Pharmacol. (2010): 5(1):103-21. 13. Di Marzo V, Breivogel CS, Tao Q, Bridgen DT, Razdan RK, Zimmer AM, Zimmer A, Martin BR. “Levels, metabolism, and pharmacological activity of anandamide in CB(1) cannabinoid receptor knockout mice: evidence for non-CB(1), non-CB(2) receptor-mediated actions of anandamide in mouse brain.” J Neurochem. (2000): 75(6):2434-44. 14. Oláh A, Tóth BI, Borbíró I, et al. “Cannabidiol exerts sebostatic and anti-inflammatory effects on human sebocytes.” J Clin Invest (2014): 124(9):3713-3724. 15. Gollnick HP, Zouboulis CC. “Not all acne is acne vulgaris.” Dtsch Arztebl Int (2014): 111(17):301-12. 16. Dobrosi N, Toth BI, Nagy G, et al. “Endocannabinoids enhance lipid synthesis and apoptosis of human sebocytes via cannabinoid receptor-2-mediated signalling.” FASEB J (2008): 22(10):36853695. 17. Oláh A, Markovics A, Szabó-Papp J, et al. “Differential effectiveness of selected non-psychotropic phytocannabinoids on human sebocyte functions implicates their introduction in dry/seborrhoeic skin and acne treatment.” Exp Dermatol (2016): 25(9):701-707. 18. Inci R, Kelekci KH, Oguz N, Karaca S, Karadas B, Bayrakci A. Dermatological aspects of synthetic cannabinoid addiction. Cutan Ocul Toxicol. 2017;36(2):125‐131. doi:10.3109/15569527.2016.1169541. 19. Ali A, Akhtar N. “THe safety and efficacy of 3% Cannavis seeds extract cream for reduction of human cheek skin sebum and erythema content.” Pak J Pharm Sci (2015): 28(4):1389-1395 20. Cork MJ, Danby SG, Vasilopoulos Y, et al. “Epidermal barrier dysfunction in atopic dermatitis.” J Invest Dermatol (2009): 129(8):1892-908. 21. Bieber, T. “Atopic Dermatitis.” Ann Dermatol (2020): 22(2):125-37. 22. Wollenberg A, Seba A, ANtal AS. “Immunological and molecular targets of atopic dermatitis treatment.” Br J Dermatol (2014): 170:7-11. 23. Carbone A, Siu A, Patel R. “Pediatric atopic dermatitis: a review of the medical management.” Ann Pharmacother (2010): 44(9):1448-1458. 24. Eberlein B, Eicke C, Reinhardt HW, Ring J. “Ajuvant treatment oof atopic eczema: assessment of an

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Clinical Research

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emollient containing N-palmitoylethanolamine (ATOPA study).” J Eur Acad Dermatol Venereol (2008): 22(1):73-82. 25. Yuan C, Wang XM, Guichard A, et al. “N-palmitoylethanolamine and N-acetylethanolamine are effective in asteeatotic eczema: Results of a randomized, double-blind, controlled study in 60 patients.” Clin Interv Aging (2014): 9:1163-1169. 26. Scheau C, Badarau IA, Mihai LG, et al. “Cannabinoids in the Pathophysiology of Skin Inflammation.” Molecules (2020): 25(3):652. 27. Ramot Y, Sugawara K, Zákány N, Tóth BI, Bíró T, Paus R. “A novel control of human keratin expression: cannabinoid receptor 1-mediated signaling down-regulates the expression of keratins K6 and K16 in human keratinocytes in vitro and in situ.” PeerJ. (2013). 28. Wilkinson JD, Williamson EM. “Cannabinoids inhibit human keratinocyte proliferation through a nonCB1/CB2 mechanism and have a potential therapeutic value in the treatment of psoriasis.” J Dermatol Sci. (2007): 45(2):87-92. 29. Brooks JP, Malic CC, Judkins KC. “Scratching the surface - managing the itch associated with burns: a review of current knowledge.” Burns (2008): 34(6):751-760. 30. Scarampella F, Abramo F, Noli C. “Clinical and histological evaluation of an analogue of palmitoylethanolamide, PLR 120 (comicronized Palmidrol INN) in cats with eosinophilic granuloma and eosinophilic plaque: a pilot study.” Vet Dermatol (2001): 12:29-39. 31. Visse K, Blome C, Phan NQ, Augustin M, Stander S. “Efficacy of body lotion containing N-palmitoylethanolamine in subjects ith chronic pruritus due to dry skin: a dermatocosmetic study.” Acta Derm Venereol (2017): 97(5):639-641. 32. Wurcel AG, Merchant EA, Clark RP, Stone DR. “Emerging and underrecognised complications of illicit drug use.” Clin Infect Dis (2015): 61(12):1840-1849. 33. Spaderna M, Addy PH, D’Souza DC. “Spicing things up: synthetic cannabinoids.” Eur J Clin Pharmacol. (2013): 69(3):373-6. 34. Ligresti A, Moriello AS, Starowicz K, Matias I, Pisanti S, De Petrocellis L, Laezza C, Portella G, Bifulco M, Di Marzo V. “Antitumor activity of plant cannabinoids with emphasis on the effect of cannabidiol on human breast carcinoma.” J Pharmacol Exp Ther. (2006): 318(3):1375-87. 35. Carpi S, Fogli S, Polini B, Montagnani V, Podestà A, Breschi MC, Romanini A, Stecca B, Nieri P. “Tumorpromoting effects of cannabinoid receptor type 1 in human melanoma cells.” Toxicol In Vitro (2017): 40:272-279. 36. Zhang X, Wang JF, Kunos G, Groopman JE. “Cannabinoid modulation of Kaposi’s sarcomaassociated herpesvirus infection and transformation.” Cancer Res. (2007): 67(15):7230-7.

D ON’T M ISS YOU R CHAN CE TO BE RECOGN ISE D!

E N T RY C LOS E S J ULY 3 1

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Understanding Laser Plumes Physicist and bioengineer Mike Murphy explores the evidence of surgical plumes following laser and IPL treatments and explains how practitioners can ensure operator and patient safety The potential issues associated with lasergenerated plumes have been known since the 1960s when lasers were first applied to treat human tissue.1 ‘Plumes’ and ‘aerosols’ are collective names typically used to describe the air contaminants following laser and intense pulsed light (IPL) treatment of tissues. They include both combustion and non-combustion-generated products including tissue(s), gases, particulate materials, steam and carbonised material (smoke).2,-5 Plumes are generated as a result of imparting high energy light onto tissues – regardless of which type of laser or IPL system is used. Even ‘non-ablative’ systems can induce plumes, and evidence indicates that standard clinical parameters are sufficient to generate potentially hazardous plumes. The evidence is quite clear – there is always some level of risk when using high energy lasers on tissues.1,2,3 The concern around plumes arising from laser/IPL treatments has been highlighted and presented as an issue in the US for five decades since it was first raised in 1967,1 yet it is rarely discussed here in the UK. Given the potential hazards such plumes may generate, especially in the current climate of COVID-19, I feel it is important to raise the awareness of this problem amongst all laser/ IPL operators.

Clinical evidence through the decades Concerns around laser/IPL plumes were first raised in 1967 by Hoye et al. when they noticed airborne particulate matter following treatment of tumours with a Nd:YAG laser.1 At the time, there was no direct evidence that such plumes posed a health risk. Tomita et al. (1981) described the mutagenetic effects of viral particles in the plumes generated by both lasers and electrocauterisation, showing that the method of release of these hazardous particles into the atmosphere is not important.5 In 1988, Garden et al. analysed the plume generated during CO2 laser irradiation of plantar and mosaic verrucae and found

smoke, vapourised tissues, steam and particulates including some intact cells.2 Until this study it had been thought that this laser destroyed any viable tissues or viruses. In 1988, Garden found intact human papillomavirus (HPV) DNA in the plume in two out of seven patient treatments, using standard clinical laser parameters. They found that even with power densities of up to 38,200W/cm2 there was still evidence of intact viral DNA in the plume, regardless of the laser mode (pulsed, continuous, focused or de-focused). Clearly, the evidence shows that there is a real risk of cross-infection from plumes generated during laser procedures. A report by Hallmo and Naess (1991) discusses a 44-year-old laser surgeon who presented with laryngeal papillomatosis with the conclusion that he had contracted the HPV virus from treatment of anogenital condylomas using a 100W Nd:YAG laser.6 This occurred even though he was wearing conventional masks, gloves and laser eye protection glasses. A ‘standard’ smoke evacuator was also used during the procedures. Ziegler (1998) found that aerosols generated by Er:YAG lasers applied to recombinant retrovirus cell lines contained ‘infectious viruses, viral genes or viable cells and may promote the spread of infections or tumour cell dissemination’.7 A later study by Garden (2002) found viable bacteriophages, in addition to viable human immunodeficiency virus and HPV particles in laser plumes.3 Another study by Mihashi et al. showed that when the smoke extraction tip was moved only 2cm from the treatment area, up to 50% of the particulate matter escaped into the local environment.4 In addition to biological materials in electrosurgical plumes, other evidence indicates the presence of noxious chemicals. In 2003, Barret and Garber found benzene, butene, formaldehyde, hydrogen cyanide, phenol and many other substances in the plume following treatments such as electrocautery, ultrasonic scalpel tissue

New COVID-19 laser/IPL guidance With my assistance, and the support of Dr Godfrey Town, the British Medical Laser Association (BMLA) has released new guidance for COVID-19 titled ‘Clinical Guidance for Laser Procedures during the COVID-19 Pandemic’.12 This guidance highlights the importance of Personal Protective Equipment (PPE) to avoid contamination. The guidance states, ‘Until such time that evidence to the contrary is available, one could assume that the main route of COVID-19 infection in laser/ IPL procedures remains patient-generated respiratory aerosol but still consider laser generated plume/aerosol as potentially infective’. I recommend all practitioners become familiar with the new guidance.

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EU – European Standard EN 149:2001 + A1:2009

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US – National Institute for Occupational Safety and Health standards

FFP1

• • •

Minimum filtration – 80% Maximum leakage – 22% May be used as a ‘dust’ mask

Class N

‘Non-oil’ meaning that it must be used in an environment where no oil-based particulates are present in the atmosphere.

FFP2

• • •

Minimum filtration – 94% Maximum leakage – 8% Used as protection against influenza viruses

Class R

Means that the mask is resistant to oil-based particulates for eight hours.

FFP3

• • •

Minimum filtration – 99% Maximum leakage – 2% Protects against very fine particles such as asbestos

Class P

Indicates that the mask is oil proof.

Rating:

These ratings apply to Classes N, R and P:

95

Filters out at least 95% of particles down to 0.3 microns in size

99

99% filtration down to 0.3 microns

100

99.97% filtration

Table 1: Standards for respirators in the EU and US.13-16

dissection and laser tissue ablation.8 Higgins presented an interesting report at the American Society for Laser Medicine and Surgery (ALSMS) Boston meeting in 2016 where she presented a similar list of noxious substances found in the plume following laser hair removal.9 Anyone who has been involved in the removal of hair using either laser or IPL systems can’t have failed to notice the strong smell of contaminants in the atmosphere. A 2016 report by İlçe et al. detailed the hazards of exposure to plume arising from electrosurgery including headaches, coughing, nausea and drowsiness in 81 medical personnel.10 My own findings in 2018 showed that micron-sized particles of tattoo ink leave the skin at high velocity during laser treatments. While these ink fragments may not pose a biological threat in themselves, some of these particles fly through blood vessels, thereby potentially picking up contaminants in the blood.11 Although there has been no specific tests conducted, it is safe to assume that standard cotton surgical facemasks would not be effective in stopping these high-speed fragments.

Safety and Health Administration clearly indicates that surgical masks used to prevent contamination of the patient are not certified for respiratory protection of medical employees.13 In other words, standard surgical masks may not be suitable personal protective equipment (PPE) against laser-generated plumes, in many cases. Surgical masks are essentially disposable, lightweight paper tools designed to protect patients from caregivers. They are only effective for between three and eight hours and offer very little protection to the wearer against airborne infectious agents, such as viruses.14 Given the current COVID-19 pandemic we have all become aware of the wide variety of face masks available. However, it is important to understand which masks provide the correct level of protection against small air-borne particulates. It is also important to differentiate between ‘masks’ and ‘respirators’.13,14,15 Masks are essentially designed to prevent the wearer from contaminating patients, while respirators are PPE designed to prevent the inhalation of smoke, gases and biohazards.

Protection against plumes

Surgical masks: these are medical devices designed to prevent transmission of water droplets from the wearer to the Plume awareness associations environment. These The US has an established organisation called the devices are tested for International Council on Surgical Plume, which is a nonbacteria filtration in the profit clinical advocacy organisation with a membership of direction of exhalation more than 150,000 healthcare professionals and colleagues – from inside to the through professional societies and organisations.19 To help external environment. raise awareness to both patients and practitioners of the importance of measures to protect human health locally, Respirators: are myself and my colleague, Dr Z Adam Kader recently disposable or refounded The UK Council for Surgical Plumes.20 useable medical

The evidence clearly shows that laser/IPL plumes must be considered as a biohazard. Appropriate measures must, therefore, be taken to protect the laser/IPL operators and their patients. These include gloves, gowns or scrubs, appropriate masks, high flow rate suction systems with good filtration and proper training in their use. Masks and respirators Standard surgical masks have been found to effectively prevent transmission of particles larger than five microns in size.8 However, the US Occupational

devices tested in the direction of inhalation – from the outside environment to the wearer’s respiratory system. They are designed to minimise transmission of unwanted particulates, including bacteria and viruses, to the wearer’s respiratory system. They must be properly fitted to ensure efficiency. Note that some respirators come with an optional exhalation valve to reduce resistance to exhaled air (for the comfort of the wearer).13-16 In Europe, all respirators must comply with the European Standard EN 149:2001 + A1:2009 with three classes of disposable particulate respirators – FFP1, FFP2 and FFP3.14 In the US, respirators must comply with the NIOSH Standard and include N95, N99 and N100 classes.15 The types of respirators are outlined in Table 1.13-17 Appropriate protection for surgical plumes To protect the practitioner, well-fitting respirators that are at least FFP2 or N95 are required (or FFP3/N99 in areas of intense plumes or high viral loads).13-16 Smoke extraction equipment in clinics Use of appropriate smoke extraction equipment is critical and includes those with high-efficiency particulate absorbing (HEPA)

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filters. Such filters are designed to remove 99.97% of ‘particles’ larger than 0.3 microns from the air – according to the Standard EN 779:2012.18 They must also be properly used, otherwise it can give both patients and operators a false sense of security. HEPA filters can be cleaned but frequent changes of the filters should be carried out to ensure a sufficiently high suction flow rate.

Conclusion It is a mandatory legal requirement for safety glasses to be worn by both practitioner and patient when using laser/IPL equipment.17 I believe that other PPE should also be mandatory for protection against laser/IPL plumes. Based on the evidence, it should be always be assumed that the laser/IPL plume is infectious with potentially dangerous viruses, and other pathogens, and appropriate measures should be taken to minimise crossinfections. Note: This article has been repurposed from an upcoming book by Mike Murphy titled ‘Lasers & IPLs in Medicine and Aesthetics’. It is due to be published as an e-book in the near future. Mike Murphy is a physicist and bioengineer with 34 years’ experience in medical lasers. He started Dermalase Ltd in 1989 to launch the QS ruby laser into medical markets in the US, EU and Asia. Murphy is currently the General Secretary of the UK Council for Surgical Plumes and General Secretary of the Association of Laser Safety Professionals, is a Certificated Laser Protection Adviser and is registered as an LPA with Healthcare Improvement Scotland. He has published more than 25 articles, reports and papers in peer-reviewed medical laser journals and trade publications. Qual: B.Sc., M.Sc., LPA

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REFERENCES 1. Hoye R.C., Ketcham A.S., Riggle G.C. The air-borne dissemination of viable tumour by high-energy neodymium laser. Life Sci. 1967; 6:119-125 2. Jerome M. Garden, MD; M. Kerry O’Banion, MD, PhD; Lori S. Shelnitz, MD; et al. Papillomavirus in the Vapor of Carbon Dioxide Laser-Treated Verrucae. JAMA 1988;259:1199-1202 3. Jerome M. Garden, M. Kerry O’Banion, Abnoeal D. Bakus, Carl Olson. Viral Disease Transmitted by Laser-Generated Plume (Aerosol). Arch Dermatol, Vol. 138, Oct 2002,1303-1307 4. Mihashi S., Ueda S., Hirano M. et.al. Some problems about condensates induced by CO2 laser irradiation. Report presented to the Fourth International Society for Laser Surgery, Tokyo, November 1981. 5. Tomita Y, Mihashi S., Nagata K. et.al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutat Res. 1981; 89:145-149 6. Hallmo P., Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol. 1991; 248:425-427 7. Ziegler B.L., Thomas C.A., Meier T., Müller R., Fliedner T.M., Weber L. Generation of infectious retrovirus aerosol though medical laser irradiation. Lasers. Surg. Med. 1998; 22:37-41 8. Barrett, W. L., & Garber, S. M. (2003). Surgical smoke: a review of the literature. Surgical Endoscopy, 17(6), 979–987 9. Kachiu Lee Higgins et.al., Laser Hair Removal: What is in the Plume? ASLMS Conference, Boston, 2016. Abstract LB22 10. İlçe A., et al. The examination of problems experienced by nurses and doctors associated with exposure to surgical smoke and the necessary precautions, Journal of Clinical Nursing 26(11) June 2016. 11. Murphy M.J., High Speed Aggregates are Ejected from Tattoos During Q-switched Nd:YAG Laser Treatments, Lasers in Surgery and Medicine, 2018; 9999:1-7 12. BMLA, Resumption of Laser/ IPL skin services post COVID-19 lockdown- British Medical Laser Association (BMLA) guidance document. May 2020, <https://www.bmla.co.uk/category/blog/> 13. NIOSH, COVID-19 Information for Workers. <https://www.cdc. gov/niosh/index.htm> 14. European Standard EN 149:2001 + A1:2009, Respiratory protective devices - Filtering half masks to protect against particles - Requirements, testing, marking. <https://standards. cen.eu/dyn/www/f?p=204:110:0::::FSP_PROJECT,FSP_ORG_ ID:32928,6062&cs=1FC98AD34A5EE26A0CB5A6155ED4D6E5E> 15. HSE, Respiratory protective equipment at work A practical guide. <https://www.hse.gov.uk/pUbns/priced/hsg53.pdf> 16. OSHA, Laser/Electrosurgery Plume. <https://www.osha.gov/ SLTC/laserelectrosurgeryplume/standards.html> 17. BS EN 60825-1: 2014. Safety of laser products: Part 1. Equipment classification and requirements <https://shop.bsigroup.com/ ProductDetail?pid=000000000030364399> 18. HEPA filters <http://www.hepa.com> 19. International Council on Surgical Plume <https://www.plumecouncil.com/about.phtml> 20. The UK Council for Surgical Plumes, 2020. <http://www.ukcsp. co.uk>

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Understanding Xanthelasma Dr Firas Al-Niaimi explores the aetiology and treatment options for the dermatological condition presenting on patientsâ&#x20AC;&#x2122; eyelids Xanthelasma, also called xanthelasma palpebrarum (XP), are yellowish papules and plaques caused by localised accumulation of lipid deposits commonly seen on the eyelids. The global prevalence is estimated at 4%,1 with an incidence of 1.1% in women and 0.3% in men.2 The age of onset can range from 15 to 73 years, although typical peaks are seen in the fourth and fifth decades. In around half of the cases it can be associated with an underlying hyperlipidaemia and a presentation prior to the age of 40 should prompt screening to rule out underlying inherited disorders of lipoprotein metabolism.3 Whilst the exact pathogenic mechanism is not fully understood, cutaneous xanthelasma represent the deposition of fibroproliferative connective tissue associated with lipid-laden histiocytes, also known as foam cells.4 Primary hyperlipidaemia is caused by genetic defects in the receptors or enzymes involved in lipid metabolism. Inherited disorders of low-density lipoprotein (LDL) cholesterol metabolism are typical examples that are seen in 75% of those with familial hypercholesterolaemia.2 The pathogenesis in this cohort of patients is thought to be secondary to elevated serum lipoprotein levels, which leads to extravasation of the lipoprotein through dermal capillary blood vessels and subsequent macrophage engulfment.1,2 Secondary causes of hyperlipidaemia include certain physiological states and systemic diseases. Examples include pregnancy, obesity, diabetes mellitus, hypothyroidism, nephrotic syndrome and cholestasis.5-8 Certain medications such as oestrogens, tamoxifen, prednisolone, oral retinoids, cyclosporine and protease inhibitors, can also lead to a state of hyperlipidaemia.9-11 The most common cutaneous presentation of secondary hyperlipidaemia is XP.2 They present as soft symmetrical, bilateral, yellow, thin polygonal papules and plaques typically in the periorbital area (Figure 1). Other sites that may be affected include the neck, trunk,

shoulders and axillae.2 There is no reported association between xanthelasmas and highdensity lipoprotein (HDL) or triglyceride levels. Christoffersen et al.12 found that independent of well-known cardiovascular risk factors, the presence of XP appears to be a predictor of risk for myocardial infarction, ischaemic heart disease, severe atherosclerosis, and death in the general population. Contrary to common belief, arcus senilis of the cornea is not an independent predictor of risk of the cardiovascular concerns listed above.12 The differential diagnosis of xanthelasma includes chalazion, sebaceous hyperplasia, syringoma, nodular basal cell carcinoma and necrobiotic xanthogranuloma (NXG).13 XP are typically asymptomatic and treatment is often sought for cosmetic purposes. Unfortunately, there is paucity of strong evidence in the literature for the effective treatment of XP. Nevertheless, current treatment options are discussed. There is limited evidence in the literature for the effective treatment of normolipidaemic (not-elevated lipids) XP. Commonly cited treatments include topical trichloroacetic acid (TCA), laser ablation, and surgical excision. There are also case reports of XP responding to systemic interleukin-1 blockade and cyclosporine-A therapy.10,14 Below are the most common treatment modalities used for normolipidaemic XP, their associated efficacy, particular limitations and side-effects.

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Probucol There are reports of successful treatment using oral probucol in the literature. It is proposed that probucol, an antioxidant, acts by potentially inhibiting atherogenesis through limiting the oxidative modification of low-density lipoprotein cholesterol essential for foam cell formation.15 Harris et al. showed 68% of xanthelasma regressed after probucol therapy in seven cases.16 Alirocumab Alirocumab, a monoclonal antibody which belongs to a novel class of anticholesterol therapy through inhibition of PCSK9, is primarily used in the treatment of hypercholesterolemia. Civeira et al.17 reported rapid resolution of XP after treatment with alirocumab in a middle-aged man with severe high levels of LDL cholesterol, due to a familial hypercholesterolemia. The regression of the XP was associated with lowering of LDL cholesterol concentrations.17

Topical therapy Topical therapy is probably the most widely used modality, particularly in clinics or settings that lack energy-based devices. Chemical peel Trichloroacetic acid (TCA) is a form of destructive therapy, used topically at concentrations of 50-100%. The approach is relatively simple. It is applied in a painting fashion; carefully ensuring the greatest amount of TCA is smeared at the margin of the lesion. The treatment endpoint is white frosting. One study reviewed the efficacy and tolerability of different concentrations of TCA in the treatment of 30 patients with XP.18 TCA concentrations of 35%, 50%, and 70% were trialled. The authors initially degreased the skin using cotton gauze soaked in acetone. Sensitive areas, for example, the inner canthus and nasolabial folds, were protected with petrolatum ointment. The TCA was then applied using a cotton-tipped

Systemic therapy Whilst systemic therapy in practice is rarely used in XP, there are nevertheless emerging drugs that have shown to be associated with XP regression. These drugs include probucol and alirocumab.

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Figure 1: Presentation of xanthelasma

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applicator until solid frosting without pink background was achieved. This was usually seen within 30 seconds to two minutes. The area was then neutralised and rinsed with cold water, followed by the application of a thin coat of antibiotic ointment and sunscreen.18 TCA 70% was found to be the most effective concentration. It was welltolerated and associated with significant clinical efficacy. This concentration required the least number of sessions in the treatment of XP. Furthermore, it was noted that TCA 70% was particularly useful in treating papular lesions, whilst TCA 50% was effective for macular (flat) xanthelasma. A study by Haque and Ramesh mirrored these findings.19 They also concluded that TCA 70% was effective in treating flat plaques, however TCA 100% was required for papulonodular lesions.19 In practice, this translates to lesion thickness; the thicker the lesion, the higher the required concentration. Overall, TCA therapy for XP was found to be more effective for smaller lesions, with repeated procedures resulting in pigmentation and scarring.20 In general, postinflammatory hyper and hypopigmentation with TCA is reported at a frequency of 9-12.5% and 21.5-33.4%, respectively.19,21 Some studies reported that this was dependent on the TCA concentration, whilst others did not corroborate this association.19,21,22 It is also important to note that with any procedure close to the eye, care should be taken given the risk of ocular injury and the thin skin. Existing literature suggests recurrences ranging between 25 to 39%,19-21 with Goal et al. describing a recurrence rate of 34.5% at six-month follow-up in their cohort.23 Liquid nitrogen cryotherapy Liquid nitrogen cryotherapy is a simple and effective treatment option. The risk of intense swelling due to the lax skin tissue in the eyelid is the reason this treatment is generally avoided in XP. One small case series involving four patients did show efficacy in the treatment of XP using very short freeze time.24 They reported clearance of lesions in all cases with only minor swelling associated, and no recurrences during a 10-year period. The proposed mechanism of action of cryotherapy is suggested to be associated with vasoconstriction and microthrombi formation caused by cryo-induced cell death. Potential adverse effects seen with cryotherapy include oedema, vesicular and blister formation depending on intensity of inflammatory response. These correlate with the length of freezing and thus the temperature that the tissue reaches.24

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Pingyangmycin Intralesional Pingyangmycin was described in one study by Wang et al.25 This is a broad-spectrum anti-tumor antibiotic. A total of 12 patients with 21 lesions received two treatment sessions, and in all patients except one the result was satisfactory. One patient experienced local recurrence 12 months after treatment. The authors described no severe associated complications.25

Energy-based devices Radiofrequency ablation Low-voltage radiofrequency (RF) ablation was used in a study for the treatment of XP.26 Out of the 15 patients who participated in the study, nine achieved an improvement of greater than 75%. The authors concluded that this modality of treatment was effective in the treatment of XP, in particular lesions close to the eye and those that are multiple, especially with indistinct borders.26 A comparative study by Reddy et al. evaluated the efficacy of RF ablation versus TCA in the treatment of XP.27 Although both treatments resulted in similar improvement scores, RF ablation required fewer sessions to achieve more than 75% clearance of lesions. However, at four weeks post treatment, 40% in the RF group and 15% in the TCA group had scarring, and 45% in the RF group and 30% in the TCA group had pigmentation.27 So whilst fewer treatment sessions were required with RF ablation to achieve an excellent result, the treatment was associated with more complications comparatively in this study. Laser ablation Laser ablation has been used to deliver targeted therapy in the treatment of XP. The mechanism of action, in addition to lesion vaporisation, is proposed to include 1) destruction of perivascular foam cells via thermal energy damage and 2) coagulation of dermal vessels leading to blockage of further lipid leakage into tissue, thus preventing recurrence. The use of a variety of lasers has been described in the literature including carbon dioxide (CO2), argon, erbium and pulsed-dye lasers. The CO2 and Erbium:YAG use longer wavelengths of light absorbed best by cellular water, thus allowing for their use in removal of epidermal lesions.28 Argon and pulseddye lasers, on the other hand, use shorter wavelengths of light, preferentially absorbed by haemoglobin, and therefore are primarily used for vascular lesions.28 Argon lasers are no longer used in clinical practice.

Carbon dioxide laser The CO2 is considered the gold standard ablative laser. The vaporisation of water within cells results in the ablation of skin lesions layer by layer.28 A number of studies utilising the CO2 laser to treat patients with XP have been reported. The overall outcome was excellent and complete initial resolution was achieved in the majority of cases. Raulin et al. published a large case series of 23 patients receiving high-energy ultra-pulsed CO2 laser therapy.29 The ultrapulsed variation enables vaporisation of a thin layer of tissue whilst the pulses allow time for thermal relaxation of surrounding tissue, limiting excessive heat build-up.30 All lesions were successfully removed, with no scarring associated and a recurrence rate of 13% at 10 months. The authors recommended treatment should be performed in the early stages of XP development in order to prevent recurrence. A prospective randomised study involving 20 patients compared the efficacy and safety of super pulsed (SP) and fractional CO2 laser treatment for XP in bilateral XP lesions, with either a single session of ablative SP CO2 or three to five sessions of ablative fractional CO2 at monthly intervals.31 Lesions treated with SP CO2 laser showed significantly better improvements and patient satisfaction in comparison with fractional CO2 laser, although scarring and recurrence was also higher.31 The CO2 laser has also been compared to other treatment modalities. A comparison study using 30% TCA and CO2 laser for the treatment of XP in 50 patients showed that both these modalities were effective treatments for clinically mild lesions.23 The laser group achieved complete clearance in all patients, in contrast to the TCA group whom achieved a complete clearance rate of 56%. The CO2 laser was the superior treatment option for severe lesions due to its associated coagulative effect that spreads beyond the ablative zone. Unfortunately recurrence was a concern with both treatments, particularly for lesions that extended deep into the dermis. At six months, the recurrence rate with TCA was 34.8%, consistent with existing literature that report rates ranging from 2539%.19-21 In this study, the recurrence rate with CO2 at six months was 16%.23 The recurrence rates reported in the literature for CO2 are variable from no recurrence after four years32 to 13% at 10 months.29 The efficacy of CO2 laser therapy has also been compared to higher concentrations of TCA. Mourad et al.18 found CO2 laser ablation to be as

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effective as TCA 70% in the treatment of XP in 30 patients. Side effects reported include post-inflammatory hyperpigmentation (22.2%) and hypopigmentation (33.3%).18,33 Erbium:yttrium-argon-garnet laser Erbium:yttrium-argon-garnet, also known as the Er:YAG laser, is a purely ablative laser, with a smaller thermal coagulation zone in comparison to CO2 laser. The latter is associated with a potential higher risk of scarring. The Er:YAG also has the added advantage of faster healing time, shorter duration of post-laser erythema, postinflammatory hypo and hyperpigmentation.34 Mannino et al.35 treated 30 patients with a total of 70 xanthelasma using the Er:YAG laser. All lesions were effectively removed with no associated scarring or dyschromia.35 The follow-up observation period was 12 months with no recurrences reported. Similar effective results (100% lesion removal) were also seen in a study conducted by Borrelli and Kaudewitz who treated 33 xanthelasma lesions with the Er:YAG laser. 36 Another study by Lieb et al.37 found that the wound healing was slower with CO2 compared with Er:YAG laser due to its larger associated thermal necrosis zone. The latter form of laser also had excellent results in the treatment of superficial xanthelasma. Nevertheless, the authors concluded that CO2 laser was better suited for deeper lesions possibly due to its associated haemostatic property.38 The efficacy and complication rates of Er:YAG laser ablation in comparison to 70% TCA in the treatment for XP has also been reviewed. Gungor et al.38 treated different XP lesions in the same patient using these two treatment modalities. They reported that both treatments have similar effectiveness and complications rates. Q-switched Nd:YAG laser The benefits using the 1064 nm Q-switched Nd:YAG laser is not clear. Fusade39 reported a case series of 11 patients with a total of 38 xanthelasma lesions. After a single course of treatment they noted an excellent response (greater than 75% clearance) in six patients, a good response (51-75% clearance) in a further two patients and moderate (25-50% clearance) response in the remainder.39 However, it is important to note none of the patients achieved complete clearance. Furthermore, these promising findings could not be replicated by Kerasi et al.,40 who treated a total of 76 lesions in 37 patients with two sessions of Q-switched Nd:YAG

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laser (1064 nm and 532 nm wavelengths). In total 57 lesions were treated with the 1064 nm wavelength and 19 with the 532 nm wavelength. The overwhelming majority of patients showed no clearance.40 The early disappointing results accounted for the high dropout rate, therefore the authors advised against using Q-switched Nd:YAG laser treatment for XP due to poor clearance.40 I would advise against the Q-switched laser in XP given the potential ocular risk and poor evidence of efficacy. Potassium titanyl phosphate laser Potassium titanyl phosphate (KTP) laser works on the principle of selective photothermolysis and is primarily a vascular laser. One study used KTP laser (532 nm) to treat xanthelasma in 14 patients and reported an efficacy of 85.7% without side effects.41

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has been reported in the past to be up to 40% after primary surgical excision, 60% after secondary excision, and 80% with bilateral upper and lower eyelid involvement.45 Mendelson and Masson advocate that surgical excision should be the mainstay of treatment for XP lesions that involve the deep dermis or infiltrate the underlying muscle. It is therefore apparent from the literature that recurrence following surgery is higher if the lesion excised was a recurrence, there is presence of underlying hyperlipidaemia, and if all four eyelids are involved.45 Other surgical techniques include a combination approach of surgery and chemical peeling. Zarem and Lorincz recommend superficially excising the xanthelasma lesions using light electrodesiccation followed by the application of topical trichloroacetic acid.46

Conclusion Pulsed-dye laser Karsai et al.42 described the use of 585 nm pulsed-dye laser in 20 patients with XP. A total of 38 lesions were treated. The authors described promising results with majority of the patients achieving greater than 50% clearance rates. Reported side effects included purpura, oedema and postinflammatory hyperpigmentation. No longterm follow-up was mentioned.

Surgery Traditionally, surgical excision has been used and often yields excellent cosmetic outcomes with various surgical techniques advocated. The classic blepharoplasty may be used to excise the xanthelasma in a serial staged approach.43 Recurrence, however, is common, and reported to be up to 40 and 60% following primary and secondary excision, respectively.43 Lee et al. conducted a four-year retrospective review of patients who received surgery for XP.44 Patients were classified into four grades according to the location and extent of the lesion. In total, 95 cases were reviewed; 70% of which were treated with simple excision in conjunction with blepharoplasty. The remaining 30% were treated with a combination of simple excision and local flaps or skin grafts. These were performed in patients with more advanced grades of the disease. There were no associated complications apart from postoperative scar contracture (4.2%) in patients graded III or IV.44 Recurrence was reported in 3.1% of patients at 12 months and this was found to be irrespective of the grade. The incidence of recurrence, however, is increased with incomplete excisions and

Although XP lesions are considered benign, they can cause significant psychological distress due to their associated cosmetic disfigurement. Their presence can also indicate an underlying plasma lipid disorder in approximately 50% of patients caused by a lipoprotein or apolipoprotein abnormality. Patients should therefore be screened for underlying causes of hyperlipidaemia and may require follow-up for associated morbidities. XP rarely cause functional problems, however treatment is usually sought due to aesthetic reasons. Unfortunately recurrence is often seen with all therapeutic modalities and currently a gold-standard long-term treatment option has yet to be established. I recommend TCA or ablative lasers as a first choice given the current level of evidence. Dr Firas Al-Niaimi is a consultant dermatologist, Mohs and laser surgeon. Dr Al-Niaimi has written for more than 180 scientific publications, 10 book chapters and his own book on preparation for dermatology specialist examination. He is also a an honorary lecturer and senior research fellow in the dermatology and laser department at Aalborg University, Denmark, and is involved in clinical and translational research in the field of lasers. Qual: MD, MSc, MRCP, EBD

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020

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A summary of the latest clinical studies Title: Photoprotection With Mineral-Based Sunscreens Authors: Nowell Solish, Shannon Humphrey, et al. Published: Dermatol Surg, June 2020 Keywords: SPF, sunscreen, photoprotection Abstract: Although chemical sunscreens have traditionally been at the forefront of sun protection, safety concerns and increasing awareness of the environmental impact of personal-care products have led to greater interest in the use of mineral blockers as photoprotective agents. The objective was to examine the safety and efficacy of mineral-based sunscreens to allow patients to make informed choices about ultraviolet (UV) protection. A review of the literature was performed using the PubMed database. This article provides an overview of physical blockers and focuses on the efficacy of mineral sunscreens in offering broad-spectrum UV protection and safety concerns, including the controversy surrounding the use of nanoparticles. Practical tips for application are also reviewed. Mineral sunscreens are an attractive, efficacious option for consumers who prefer alternative choices in sun protection. Title: Assessment of the Potential Skin Application of Plectranthus ecklonii Benth Authors: Marisa Nicolai, Joana Mota, et al. Published: Pharmaceuticals (Basel), June 2020 Keywords: Plectranthus ecklonii, UV protection, rosmarinic acid, sun protection factor Abstract: Plectranthus ecklonii Benth. has widespread ethnobotanical use in African folk medicine for its medicinal properties in skin conditions. In this study, two different basic formulations containing P. ecklonii extracts were prepared, one in an organic solvent and the other using water. The aqueous extract only contained rosmarinic acid (RA) at 2.02 mM, and the organic extract contained RA and parvifloron D at 0.29 and 3.13 mM, respectively. RA in aqueous solution permeated skin; however, in P. ecklonii organic extract, this was not detected. Thus, P. ecklonii aqueous extract was further studied and combined with benzophenone-4, which elevated the sun protection factor (SPF) by 19.49%. No significant cytotoxic effects were observed from the aqueous extract. The Staphylococcus epidermidis strain was used to determine a minimum inhibitory concentration (MIC) value of 10 µg.mL-1. The aqueous extract inhibited the activity of acetylcholinesterase by 59.14 ± 4.97%, and the IC50 value was 12.9 µg.mL-1. The association of the P. ecklonii extract with a UV filter substantially elevated its SPF efficacy. Following the multiple bioactivities of the extract and its active substances, a finished product could be claimed as a multifunctional cosmeceutical with broad skin valuable effects, from UV protection to antiaging action.

Title: Herpes Reactivation After the Injection of Hyaluronic Acid Dermal Filler: A Case Report and Review of Literature Authors: Chenyu Wang, Tianyu Sun, et al. Published: Medicine (Baltimore), June 2020 Keywords: Dermal filler, hyaluronic acid, complications Abstract: Hyaluronic acid injections is relatively safe with little risk of complications. Although herpes reactivation after the injection of hyaluronic acid is rare, it produces quite a huge pressure and panic on patients. Quite a lot cosmetic practitioners have no awareness of preventing, diagnosing, and giving correct treatment in time due to lack of experience. A 24-year-old woman presented with erythema, crusted papules, pain and swelling on the nose after receiving the injection of hyaluronic acid. A swab of the discharge fluid was obtained for bacterial and viral culture, showing positive for herpes simplex virus. The patient was diagnosed as herpes reactivation after the injection of hyaluronic acid. The patient underwent antiviral therapy with acyclovir 400 mg, 3 times daily for seven days. After a week of antiviral treatment, the clinical signs improved. Herpes reactivation after the injection of hyaluronic acid is quite rare but needed sufficient attention of cosmetic practitioners to make the proper diagnosis, prevention and treatment. Title: Is There a Therapeutic Effect of Botulinum Toxin on Scalp Alopecia? Physiopathology and Reported Cases: A Systematic Review of the Literature Authors: R Carloni, L Pechevy, et al. Published: J Plast Reconstr Aesthet Surg, May 2020 Keywords: Alopecia, botulinum toxin, hair growth Abstract: Botulinum toxin is a treatment whose effectiveness has been widely demonstrated in the treatment of facial wrinkles. Its use in alopecia has been much less studied in the literature. Therefore, we carried out a systematic review of the literature in December 2019 in order to index published cases of alopecia patients treated with botulinum toxin. Pub Med, Embase, and Cochrane Library databases were explored. Six studies that included 94 patients were selected. Only one study was prospectively controlled against placebo. Of the 94 patients, 85 were affected by androgenetic alopecia, 8 by alopecia areata, and 1 by radiation-induced alopecia. The doses injected per session varied between 30 and 150 units and the number of sessions between 1 and 12. In the majority of the studies, the injections were carried out in all the muscles of the scalp (frontal, temporal, peri-auricular, occipital). Four studies showed a frank improvement in hair growth. Two of them showed improvement in hair density using an objective endpoint (hair count). The remaining reported studies showed inconclusive results. Patient satisfaction was high across all studies, but this systematic review did not clearly demonstrate the value of using the botulinum toxin in the treatment of alopecia. Subsequent prospective randomized controlled studies are required.

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afterwards. ‘Newness’ is always a good starting point – perhaps the clinic is new, or you are launching a new treatment approach – you may be the first in your area to have a certain device or technology. Making it timely (wedding season, summer body), or in line with current beauty media trends or consumer demands that will also be of interest for the target demographic. The aim of a press event should never be to SELL or appear purely commercial – the goal is to profile yourself and educate on your offering – providing information in an engaging, creative manner which gives journalists good content to write about, or share on social media. Your strengthened brand profile and press relationships (alongside patient bookings and sales) will be the outputs further down the line.

Hosting Press Events PR and communications consultant Julia Kendrick provides practical tips for holding clinic press events to raise your brand image while building valuable relationships and coverage opportunities Although 2020 has not exactly been the year for events, with the end of lockdown looming, now is a good time to think about how you can re-engage with both customers, and press via an event, when safe to do so. When planned and executed correctly, press events can be an effective tool to build your clinic brand and reputation. By developing relationships with key local and national press, bloggers and influencers, you can establish yourself as a source of information and authority whilst reaping long-term benefits from new business leads, to sales and brand-building opportunities. In addition, a press event gives the opportunity to raise your profile with prospective brand partners whilst outshining local competitors. Most clinics

only consider holding events at their launch, however a regular event schedule can be highly successful at building and maintaining not only your profile, but also your profit margin. Whether you enlist the services of a PR or events company, or choose to run your own event, this article will outline the key steps to success to generate long-lasting benefits for you and your clinic.

Step 1: Perfected planning The most crucial element is focusing your event on a topic that will be of interest to journalists/influencers and their readership demographic. If you fail to sufficiently grab their interest, they will likely not attend – or may attend and not write any articles

A regular event schedule can be highly successful at building and maintaining not only your profile, but your profit margin

What is the best time for press? For national press, we often hold breakfast events from 9-10am to maximise the chance of attendance and to avoid a knock-on effect on the rest of their working day. I have found that it can be tricky for press to get away from their desks at lunchtime or in the evening, unless the event is more exclusive or personalised in nature – such as an intimate press dinner. For regional press and freelancers, timings tend to be more flexible. You can always hedge your bets by including two timeslot options for your press event on the invitation and hold two sessions, or see which option garners the most positive responses. For breakfast events, we would always recommend light drinks and nibbles, as press will often not have the chance to get food if coming straight to your session. Do check local business guides to ensure there are no other events planned on your day which will monopolise the journalists’ time! Where should you hold a press event? Where appropriate, your press event should be held in the clinic as this is the easiest way to get people through your door, experience the treatments/brands on offer and understand your offering. Make sure you clear your booking calendar for an hour pre and post-event – you don’t want the stress of ushering patients out when you’ve got an event to run. If your clinic is not suitable for hosting groups, you could consider local event venues such as hotel meeting rooms, restaurant private dining rooms, or bespoke event spaces. Points to consider for external venues are obviously cost and availability,

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Virtual events With social distancing likely to be the new normal, many brands have pivoted to hosting virtual press events which can be a great way to showcase your business without the associated costs and risks of hosting an in-person event. However, approach with caution! Based on our press insights, virtual Zoom events have now lost their novelty appeal, and will soon be over-used and uninteresting for press (also it’s even easier for virtual ‘no shows’ to leave your event flatlining). To mitigate this, you could host an engaging ‘live’ event broadcast on social channels (which you can promote online in advance) and then save down as an evergreen piece of content to continue to drive awareness and engagement. Additional video presenters and participants from different locations/disciplines or expertise, alongside pre-recorded segments and live Q&As will help keep the format interactive and enjoyable.

but also whether they will allow you to bring in/administer your treatments, equipment or beds. Of course, Government guidance on social distancing measures is changing week by week, so ensure that all facets of your event are in accordance with these recommendations as well. Who should you invite? Research beauty and news journalists from your local and regional newspapers and magazines, alongside influential local bloggers and influencers who focus on beauty, wellness and aesthetics. If you need to verify or expand your contact list and aren’t sure where to begin, start by raiding the newsagents and buy samples of local press such as newspapers, magazines and ‘what’s on guides’ to review their content and identify relevant journalists. Also investigate local business or beauty bloggers, alongside Facebook groups, Twitter hashtags, and ‘what’s on’, local business directories. Checking with your patients about what local titles, blogs and influencers they read can also be a great source of information! How and when to invite? Email is the preferred method for press invitations – you can usually find journalists names as a byline next to their articles, and

their email is usually on the publication’s website. If you are connected on Instagram, you can send a direct message to ask for the best email address to send an invite to. Begin with a properly personalised cover note using the journalists’ names (no ‘Dear all’ emails as this looks sloppy and impersonal) and give a brief elevator pitch about you and your business, and what the event will entail. Explain what they will learn from the event and why this will be of interest to their readers. Paste a simple, yet visually appealing invitation design into the email body and also as an attachment – beware of making the file size too big as these can often bounce or be blocked by spam filters. Canva is a great online tool for creating your own designed materials for free. I usually give at least a month’s notice for national press events – but two to three weeks’ notice should be sufficient for regional events. Remember to always follow up after a few days and thereafter once per week until you get a response.

Step 2: Excellent execution Aim to keep your event to a maximum of 1-1.5 hours and ensure there is a clear agenda set in advance – this allows plenty of time for people to mingle, ask questions and see what is on offer at your clinic.

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Bear in mind that people rarely arrive on time – expect at least a 15-minute delay to your given start time – particularly if it’s a breakfast event. Your agenda should include an introduction covering who you are, what you do and why, covering your unique selling points, ethos and values. If using PowerPoint for your intro, avoid slide overload and where possible, mix with live demos, videos and even case study testimonials (video or in person) to really showcase your treatments. Consider profiling easy, non-invasive and quick treatments during the event – these can be performed by a member of your team to leave you free to talk it through and engage with attendees. Goody bags are a great way to pass out marketing materials – such as clinic brochures, treatment information leaflets, your bio/business card, a press release on the key event topic and special offers. Invest in reusable branded bags if possible – it’s great advertising! You can also include other branded goodies at your event to give out, like eye masks or cookies (Figure 1). Consider also reaching out to suppliers and non-competing local businesses for support – they may be able to provide free giveaways or special offers. To minimise stress on the day, ensure the venue is set up (décor, catering etc.) and pack your goody bags the night before. Prepare a registration list based on invite responses so that confirmed attendees can then be ticked off upon arrival (get someone to help you with this as you’ll be needed elsewhere!). Consider booking a photographer or even paying to have the event filmed – this creates a wealth of content for your website, social media and patient newsletters. Providing good quality photographs improves your chances of local media coverage, as many smaller publications can’t reliably get their own photographers to attend events. Be mindful of consent and ensure attendees are aware of photography/filming going on and ask anyone who doesn’t wish to be included to make themselves known.

Step 3: Maximising media interest

Figure 1 & 2: Example of branded giveaways and creative/Instagrammable touches to feature at your event

The critical tool in securing coverage is the press release, which should be included in the goody bag and on any follow-up correspondence. Press releases encapsulate the essence of the event news – what is new, how does it work, who benefits and why should people care. It must contain all the information you

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Should I include a treatment offer for press attending my event? Many practitioners have had poor experiences with offering free press treatments in return for coverage. For an educational press event, the aim would be that the content is valuable enough to secure the coverage on its own merit. If there is a specific treatment launching, consider the value of the treatment and perhaps only offer a free session to the highest value press contact. Then carefully discuss this on a one-to-one basis with the journalist to establish what you’d need to see by way of outputs; for example, a one-page feature article and social media post. Remember there is no guarantee of a positive review – it will be based on the journalists’ individual experience so consider this when offering free treatments. As always, follow industry guidelines on responsible promotion, patient care and time-limited offers when it comes to goody-bag offers and vouchers – such as the MHRA Blue Guide and the Committee for Advertising Practice guidelines.1,2

WHICH CATEGO RIES WILL YO U E NTE R? RESULTS

want the journalist to impart within their article in a succinct and punchy manner and should be one page maximum. You can learn how to create an effective press release by reading my article published on the Aesthetics website.3 The day after your event, send a friendly ‘thank you’ email to attendees – share some of the images/videos of the event and where appropriate, prompt people to come in for their consultations/special offers. Re-attach the press release and offer to help with any questions. It’s also worth reaching out to those who couldn’t make it with a mini event synopsis, the press release and imagery as they may still cover anyway. Whilst it’s tempting, don’t chase too hard for coverage outputs – the journalists should give you an idea if and when they are planning to cover, and a polite follow-up once per week is usually the best way to keep track of anticipated outputs. When coverage appears, share it via your website, social media and patient newsletters. Ensure you tag the journalist and publication to thank them for their article. This keeps relationships warm and ready for your next event!

Julia Kendrick is an awardwinning PR, communications and business strategy expert with over 16 years’ experience. She’s the CEO of Kendrick PR, which specialises in trade and consumer PR for the beauty, wellbeing and aesthetic medicine industries. Kendrick also created the E.L.I.T.E. Reputation Programme – the industry’s first online PR and marketing training developed specifically for medical aesthetic practitioners. REFERENCES 1. MHRA, The Blue Guide Advertising and Promotion of Medicines in the UK. <https://assets.publishing.service.gov.uk/government/ uploads/system/uploads/attachment_data/file/824778/ Blue_Guide.pdf> 2. CAP Advertising codes. <https://www.asa.org.uk/codes-andrulings/advertising-codes.html> 3. Kendrick, J, Effective Press Releases: The Gateway to Increased Business Potential, 2015. <https://aestheticsjournal.com/feature/ effective-press-releases-the-gateway-to-increased-businesspotential>

• BEST NON-SURGICAL RESULT • BEST SURGICAL RESULT

INITIATIVES • PROFESSIONAL INITIATIVE OF THE YEAR

PRACTITIONERS • RISING STAR OF THE YEAR • THE SPRINGPHARM AWARD FOR AESTHETIC NURSE PRACTITIONER OF THE YEAR • MEDICAL AESTHETIC PRACTITIONER OF THE YEAR • CONSULTANT SURGEON OF THE YEAR

CLINICS • BEST NEW CLINIC, UK AND IRELAND • BEST CLINIC LONDON • BEST CLINIC SOUTH ENGLAND • BEST CLINIC NORTH ENGLAND • BEST CLINIC MIDLANDS & WALES • BEST CLINIC SCOTLAND • BEST CLINIC IRELAND • CLINIC RECEPTION TEAM OF THE YEAR

PRODUCTS • THE DIGITRX AWARD FOR PRODUCT INNOVATION OF THE YEAR • INJECTABLE PRODUCT OF THE YEAR • ENERGY DEVICE OF THE YEAR • TOPICAL SKIN PRODUCT/RANGE OF THE YEAR • SURGICAL PRODUCT OF THE YEAR

Conclusion Press events are a highly valuable business strategy to build your brand profile, secure media coverage and expand your visibility among local target audiences. With some streamlined forward planning and attention to detail in the execution, clinics can create a regular events schedule that helps educate prospective patients and drive demand, alongside strengthening business relationships with industry brands, local businesses and suppliers.

COMPANIES • SALES REPRESENTATIVE OF THE YEAR • PRODUCT/PHARMACY DISTRIBUTOR OF THE YEAR • MANUFACTURER OF THE YEAR • CLINIC SUPPORT PARTNER/ PRODUCT OF THE YEAR

TRAINING • INDEPENDENT TRAINING PROVIDER OF THE YEAR • SUPPLIER TRAINING PROVIDER OF THE YEAR

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Marketing Across Generations Customer relationship specialist Duncan Stockdill explains how aesthetic businesses can target their marketing efforts more effectively to multigenerational customers It’s not so long ago that aesthetic enhancements were seen as the reserve of the older and richer generation, as well as celebrities. Now it’s become more mainstream, more socially acceptable and accessible to the masses than ever before. An industry once thwarted by controversy and secrecy, it has cast aside most of its stigma partly thanks to the growing number of celebrities and social media influencers who are open and honest about the work they have done. Such non-surgical treatments are booming as ‘polish and perfect’ and ‘tweakments’ become the mantras of the Instagram generation and an imageconscious ageing population.

Post-COVID comeback The chairman of Estée Lauder once coined the phrase ‘the lipstick index’ to describe how the health and beauty sector often defies recessions.1 But will the aesthetics specialty be able to bounce back from COVID-19 social distancing, and the recession that is likely to follow, as household disposable incomes are stretched? The pandemic has certainly hit the industry hard, with clinics legally required to shut down for the past couple of months. But as they now begin to reopen and life finally returns to the new normal, and patients return in droves to their regular practitioners after being confined to home, business could be booming. So how can clinics keep

customers across the generations coming back for more?

Getting up close and personal The days of using a one-size-fits-all marketing strategy are long in the past. Each generation, from the silent generation to Gen Z, have different characteristics, cultures, values, needs and expectations, so a campaign that works for one cohort might not necessarily work for another. Although, marketing a product or service to a broad mix of social demographics – from a sixty-something who may be uncomfortable with digital marketing to a twenty-something who texts, not talks – is a challenge. What most of the generations do have in common, however, is an innate desire or, indeed, for the younger generations, an expectation, for increasingly sophisticated personalisation from brands. Making any generation feel special and understood is key to building brand loyalty and lucrative relationships. Small gestures can make a big difference. But who can remember the birthday of every patient or where they went on holiday? Can you recall the name of a prospect’s husband or which is their favourite restaurant? Recent developments in technology are allowing businesses to build highly accurate customer profiles which then inform hyperpersonalised marketing campaigns. Customer relationship management (CRM)

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software forms the bedrock of this approach, collating critical customer information at every touchpoint – from their treatment likes and dislikes, lifestyle choices, medical issues and ideas on budget to preferred contact method. By capturing such data in one place, it can help aestheticians to build up accurate customer profiles allowing them to then micro-target smaller, niche customer segments through the most appropriate channels. A CRM system can also act as a virtual PA, automatically sending reminders about thoughtful insights, personal touches or important dates. Integrated with an email distribution platform like Mailchimp or a social media platform like Hootsuite, it then allows aesthetic practitioners to send out targeted content via the most relevant channel for each generation. From a birthday offer or ‘we’ve missed you’ discount to a how-to video, here we look at the most relevant strategies for each of the five main generations.

Generation Z (1995-2010) Typically considered as those born after 1995 (however the exact year brackets for all generations can be debated slightly), this generation grew up with technology surrounding them in their daily lives. Research has suggested that they spend a huge 10.6 hours a day engaging with online content2 and virtually all (98%) own a smartphone.3 However, choosing the right social channel on which to focus your efforts and spend your money on is key. According to one survey, almost half (49%) of Gen Zs said Instagram was their favourite social media channel, while only 18% chose Facebook as their top choice.4 Gen Zs consume their information via visual engagement.5 Video marketing should also play a key part in your strategy, so create informative how-to videos on YouTube, as well as shorter, snappier content over on Instagram showing procedures, launches and mini Q&As with practitioners. Remember to be authentic, though. Gen Zs are savvy and having been bombarded with content with most of their lives, they can quickly spot the real from the fake. Live your brand from the inside out. For example, if you’re sharing a photo of a procedure, use real photos of your practitioners doing the treatment rather than a stock image.

Millennials (1980-1994) According to Mintel, 53% of millennials consider non-surgical treatments to be an increasingly normal part of our beauty regimes,6 and aesthetics businesses are now

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frequently engaging with this cohort – one of the most technically and socially-connected demographics in society. These tech-savvy prospects crave ‘experiences’ – and this desire has drastically changed textbook marketing because they want so much more than a functional product or service that fulfils a need. A 2019 survey of 13,416 Millennials across 42 countries and territories suggests that they want to buy from companies that are ethical, transparent and socially conscious at the core of their DNA. In fact, 37% of Millennials say they have stopped or lessened a relationship with a business for not operating ethically.7 If you run an ecofriendly clinic or donate part of your profits to charity, promote it in your marketing material, certainly, but be prepared to back it up with proof and stats to avoid it being seen as a publicity stunt. In terms of which social media platform best to use, research has indicated that millennials dip in and out of many different ones.8 As a result, aesthetic businesses should have a comprehensive social media marketing plan to ensure the brand is connecting with consumers at multiple touchpoints, from Twitter and Facebook to Instagram and YouTube. This generation are notoriously more risk-averse than their two predecessors,9 so it is perhaps unsurprising that eight out of 10 say they are likely to check reviews from previous customers before making a purchase or booking an appointment.10Ask your patients to leave Google and Facebook reviews and make sure your glowing testimonials and case studies take pride of place on your website. Along a similar vein, incorporating user-generated content into your Millennial social media strategy is important. Whether that’s sharing customertaken photos, such as pre- and posttreatment, on Instagram or a vlog of their appointment on Facebook, Millennials are likely to deem user-generated content as more trustworthy than branded content, as well as humanising the brand.

Generation X (1965-1979) Generation X, born between 1965 to the late 1970s, are busy juggling childcare and elderly relatives, as well as home ownership and the peak of their careers. Email marketing is an effective medium to target Gen Xers as it is something they’re using all day long, whether that’s at work, at home, or on-the-go. Emails should be optimised for both web and mobile though. While research has indicated

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that smartphones are the primary device that Gen Xs use to access the internet, 53% still use a laptop or PC to search for a product or service when they want to buy.11 The lives of Generation Xers were in full swing when the recession hit in the late noughties, so it is perhaps unsurprising that this gave them a new mindset when it came to spending. They’re frugal and buy smart; the age group that could be most likely to value company loyalty points.12 Send them information on your loyalty scheme, share discount vouchers or set up a referral programme where they will get money off if they recommend your clinic to a friend.

Baby Boomers (1946-1964) Thanks to property booms, a buoyant economy and lack of student debt, Baby Boomers are often seen as the richest generation and have been found to have the most disposable income out of all the demographics.13 They have grown up with traditional marketing and advertising – TV, print and radio – so are much more accustomed to using those as a way to find out information rather than social media or websites. However, that doesn’t mean they don’t use the internet. According to Global Web Index, 69% of Boomers have a Facebook account,14 so Facebook Ads can be a cost-effective way to get in front of this audience as your products and services can be fed directly to them via their newsfeed. In terms of brand discovery and research, search engines are one of the top channels for Baby Boomers – 59% said they use it to research products in a survey of 13,626 people in 201815 – so aesthetic clinics should ensure their SEO is optimised to ensure website visibility and likeliness to be found.

The Silent Generation or Traditionalists (1925-1945) In their 70s, 80s and 90s, growing up through wars and economic crashes and usually retired, the Silent Generation prefer to consume news in a more traditional way. Research by Ofcom showed that of 903 surveyed individuals over the age of 65, 78% use BBC One to get their news, whereas just 10% use Facebook.16 As well as advertising in local newspapers, more affluent lifestyle magazines or targeted magazines like SAGA, direct mail with age-relevant case studies can be used to explain the treatments most valuable to this age group. Older people are also likely to still prefer to speak to someone on the telephone.17

Effective targeting for a post-COVID world Working with a disparate customer base in a sensitive, competitive and innovative market is a challenge – and will be even more so in the unfamiliar post-COVID market. But with an effective marketing strategy that individually targets each generation, aesthetic businesses can be reassured that their patients will feel understood and valued. And a happy customer is always a beautiful customer – whichever decade they were born in. Duncan Stockdill is a computer science graduate from Canterbury NZ, with 25 years’ experience in technology, creating customer engagement solutions for leading banks, insurance companies and financial institutions in both New Zealand and the UK. He co-founded customer relationship management software Capsule in 2008 to cater to small and medium-sized businesses. REFERENCES 1. Elizabeth Rigby, ‘‘Lipstick index’ smeared by recession’, Financial Times, 10 April 2009 <https://www.ft.com/ content/443d639e-25f4-11de-be57-00144feabdc0> 2. Colm Hebblethwaite, ‘Gen Z engaging with 10 hours of online content a day’, Marketing Tech News, 9 February 2018 <https://marketingtechnews.net/news/2018/feb/09/gen-zengaging-10-hours-online-content-day/> 3. Katie Young, ‘98% of Gen Z own a smartphone’, 17 October 2017 <https://blog.globalwebindex.com/chart-of-the-day/98percent-of-gen-z-own-a-smartphone/> 4. Paul Skeldon, ‘…while Instagram, beats Facebook and YouTube, to become shoppers’ favourite social and influencer platform’, Internet Retailing, 19 March 2019 <https:// internetretailing.net/mobile-theme/mobile-theme/-whileinstagram-beats-facebook-and-youtube-to-become-shoppersfavourite-social-and-influencer-platform-19274> 5. Jennifer Chan, ‘Gen Z and Gen Y: What do they want from a smartphone?’, Kantar, 24 March 2020 <https://www.kantar. com/inspiration/consumer/gen-z-and-gen-y-what-do-theywant-from-smartphones> 6. Alice du Parcq, ‘Whether you’re wavering between Profhilo, Botox or no-tox, we reveal the new fillers and fixers causing debate’, Glamour, 26 August 2019 <https://www. glamourmagazine.co.uk/article/new-controversial-fillers-botox> 7. The Deloitte Global Millennial Survey 2019, Societal discord and technological transformation create a “generation disrupted”, May 2019, p18. 8. GlobalWebIndex, Millennials Audience Report 2019, 2019, p25-27. 9. Mark Eltringham, ‘Generation Y employees see themselves as risk averse’, Workplace Insight, 27 February 2013 <https://workplaceinsight.net/generation-y-employees-seethemselves-as-risk-averse/> 10. Astrid Hall, ‘Most millennials only purchase items with online reviews, study finds’, Independent, 8 March 2018 <https://www.independent.co.uk/news/business/ millennial-online-review-products-research-internet-trustedrecommendations-a8245781.html> 11. GlobalWebIndex, Gen X Audience Report 2019, 2019, p8. < https://www.globalwebindex.com/reports/generation-x-report> 12. GlobalWebIndex, Gen X Audience Report 2019, 2019, p8. < https://www.globalwebindex.com/reports/generation-x-report> 13. Five By Five, What makes baby boomers wise to new product launches?, 2019, p5. < https://fivebyfiveglobal.com/wp-content/ uploads/2019/09/FbF_Baby_Boomers_WhitePaper_v4.pdf> 14. GlobalWebIndex, Baby Boomers Audience Report 2019, 2019, p23. < https://www.globalwebindex.com/reports/babyboomers> 15. GlobalWebIndex, Baby Boomers Audience Report 2019, 2019, p28. < https://www.globalwebindex.com/reports/babyboomers> 16. Ofcom, News consumption in the UK, 24 July 2019, p21. <https://www.ofcom.org.uk/__data/assets/pdf_ file/0027/157914/uk-news-consumption-2019-report.pdf> 17. Ofcom, ‘Ringing the changes: do phone numbers still matter?’, Ofcom, 5 January 2019 <https://www.ofcom.org.uk/aboutofcom/latest/media/media-releases/2019/ringing-changes-dophone-numbers-still-matter>

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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In The Life Of Dija Ayodele

The aesthetician and founder of Black Skin Directory tells us about life outside of lockdown it’s evolved into educating practitioners too and has won the Aesthetics Award for Professional Initiative of the Year two years in a row!

I work best in the mornings… Getting up between half four and five means the house is quiet! The children are still asleep, so I can sneak off downstairs and get started. I’ll have a lemon tea first thing, before starting my marathon of cups of coffee throughout the day! The house then wakes about 6:15am, so it’s time to get everyone ready and drop my daughter to school and son to nursery. I’ll see my personal trainer twice a week after drop-offs, doing mainly weight training. As much as I’d love a big fry up, a protein-based breakfast will follow! I work in my clinic, West Room Aesthetics in Maida Vale, three days a week, while the other days are spent working from home on admin and future plans for both the clinic and Black Skin Directory (BSD). On the days I’m home, mornings are filled with liaising with clients and virtual consultations – I do a lot of hand holding to reassure those who’ve never had skin treatments before. I mainly treat women of colour, usually aged between 25 and 45, with most suffering from acne or hyperpigmentation. When I’m in clinic, about 50% of my time is dedicated to consultations – lots of people just want to talk about their skin and purchase products. It’s worth taking this time with clients as 64% of all my consultations turn into long-term treatment plans. We only offer medicalgrade skincare, such as NeoStrata or Skinbetter Science, and our most popular procedures are microneedling and chemical peels. I get so much satisfaction from seeing people achieve their skin goals.

After lunch… It’s another chunk of work until it’s time to pick the kids up. At the moment I’m working on a really exciting project for BSD, alongside Glamour magazine! The festival-style event will feature lots of speakers and brands, educating black consumers on how best to take care of their skin. I set up BSD around two and a half years ago to connect people of colour to practitioners who can help them. While it started as a consumer platform,

What are you reading at the moment? Do Open: How a simple email newsletter can transform your business by David Hieatt. We’ve recently updated our clinic branding, so are planning to revamp our communications as well and this is really helping with ideas! Newsletters are a free way of getting your info out and helps people get to know you. I enjoy writing content and find it so valuable for client engagement!

Is there anything you would change about your working week? Quality time with family. When lockdown first came into force, it was so nice to sit on the sofa and watch TV with my husband – which I never normally do! I love my work and tend to keep going until I’m told to stop, but I know it’s important to balance it with my personal life.

What’s the one piece of advice you would give your younger self? Explore! Growing up black, you’re told you have to work twice as hard, so I didn’t really get the opportunity to take part in extracurricular activities that weren’t related to improving grades. Now, I change my daughter’s clubs on a regular basis so she has exposure to many different types of people and experiences.

We now have clinics listed on our website, allowing consumers to find appropriately-qualified and experienced practitioners to treat their skin type. Unless you’re a dermatologist, many medical professionals don’t get much training on skin, so really value what we offer and how it can help them reach a wider audience. Through BSD, we also offer guidance on brand positioning for treating black skin. Most clinics and companies have really good intentions, but are wary of getting their messaging wrong. We’re glad we are able to support by sharing feedback and making tweaks here and there!

Evenings are spent… Doing work that doesn’t need my brain engaged! After putting the children to bed, I’m back at my desk for two to three hours. In this time I do a lot of social media and content planning for the clinic and BSD. Throughout July I’ll be hosting Instagram Lives with BSD members to allow consumers to get to know them and find out about what’s available. As well as the usual treatments, we’ll be advising on dermatologic conditions of the scalp and managing children’s skin concerns. Running our events and communications takes a lot work; sometimes I wish I could just focus on my clinic, but then I’ll receive an email from someone saying they’ve just discovered BSD and how much they appreciate it. Many have told me that they feel like the content is written just for them, which makes me so proud and encourages me to keep going! The entrepreneur in me reminds myself that there is a huge market for black skincare and if practitioners realise that, they can capitalise on it too. They will meet patients who are truly appreciative, as they’ve never had this personalised advice and care available to them before. Not only is that a good thing for practitioners, but for society as a whole.

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020


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The Last Word Independent nurse prescriber Julie Scott discusses why she believes discounting aesthetic procedures is bad for business As we reopen following the shutdown caused by the COVID-19 pandemic, practitioners in the field of aesthetics in particular may notice a drop in patient enquiries. Though many patients are desperate to return to their pre-lockdown maintenance routines, many more still are struggling with reduced wages and drops in household income. As practitioners are similarly struggling with the fact that we’ve had reduced or even no income over this period, we are left wondering how to attract patients, new and existing, to fill our books again. The knee-jerk reaction is to lower prices, right? Offer a ’reopening’ or ’postlockdown’ discount? If you are considering this response I am here to persuade you otherwise. I believe discounting is a bad move for your aesthetic business, not just now, but ever.

Why I don’t discount Offering your services at temporarily lower prices may bring in patients but, in short, these will be the wrong type of patients. Discounting draws in patients who are motivated by price, and these patients will always leave you when a better deal comes up elsewhere – and they’ll tell their friends to do the same. It is much harder to build loyalty with a price-motivated patient, and remember, it is far better to keep your existing patient base than be constantly trying to regenerate and build a new one. Additionally, once you start discounting, you can’t go back. If you participate in one Black Friday sale for example, the entire following November is likely to be quiet because you’ll have patients waiting to book when they think the price will drop. And, if you disappoint them and the price doesn’t drop, again, they’re likely to go elsewhere. However, the main reason I don’t believe in discounting is because pricing is a direct reflection of the value a practitioner perceives themselves as providing. Ask yourself, why did you set your prices to be what they are? Most likely it was because you carefully considered your costs, your time, your education and experience, and decided on a price for each service based on your value.

So if you begin offering your services at less than this value, even temporarily, it sends the message that perhaps these services were not ever worth the full ticket price. You are underselling yourself. In my mind, it’s far better to have less patients paying the full price than servicing double the amount of patients to meet the same ends. In short, don’t undermine your skillset and value. It is also important to remember that these services and treatments you are providing are medical procedures that should be considered carefully by patients, not splurged on because they feel the pressure of a sale. How many purchases have you made because it was ‘a good deal’, only to never use or regret buying said purchase? I believe aesthetic procedures should never be put in this category. They should be carefully considered, discussed in detail, and decided on only after a full consultation and coolingoff period, which takes us to the regulations surrounding discounting aesthetic treatments. Offering a discount to persuade patients to ‘lock in’ a lower price or book sooner than they would otherwise (such as at the end of consultation before leaving your clinic) is not permitted according to the Department of Health’s Review of the Regulation of Cosmetic Interventions.1 In section 5.8 of this report, the Review Committee states, “A patient cannot give informed consent if they are not provided with time to reflect. It is not acceptable that patients are encouraged to commit to such a significant decision without the opportunity for careful consideration.” Therefore, offering a limited-time discount may be in violation of this. Furthermore, to run any promotion mentioning botulinum toxin or any prescription drug goes against the Advertising Standards Authority (ASA) regulations2 and, according to the Clinical Practice Standards Authority’s Overarching Principles for Consultation, ‘Financial discounts must not be used to entice patients to have multiple treatments or a ‘package deal’.3

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very hard to compete. However, to build a business long-term, it is more important to ask yourself where you want to place your efforts. Is it bringing in short-term, price-motivated patients? Or loyal, longstanding patients who have no problem paying the full price for your services because they understand what you are worth? Try to find these patients who are motivated by quality. Be clear from the beginning with your business concept – who is your ideal patient? Think about their needs, wants and behaviours and that will then determine how you entice new patients through the door. If you need convincing to try to woo high-end patients and stop discounting, there is an example that US aesthetic brand marketing strategist Adam Haroun shares, “Did you know that Louis Vuitton burns the bags they don’t sell? You will never walk into a Louis Vuitton and see a sale sign. This is because their reputation and their legacy are far more valuable than those bags they can’t sell. It is the same with your practice.” He adds, “Build your brand to be high-value based on your expertise and education, and the loyal patients will come.”4 However, this is not to say you should never give back to your patients! You can provide added value in so many other ways instead of discounting, whether it’s loyalty schemes, complementary treatments or skincare, refer a friend bonuses or gift vouchers. These can all be redeemed and will be more powerful at building relations with your patients and growing a long-term business than offering discounts would be. Overall, if you are a practice wanting to create long-term growth, I believe discounting your services is the wrong way to go. You’ll end up devaluing yourself, attracting the wrong patients, and maybe even risk violating ASA regulations.2 Instead, provide added value to your patients and watch your business grow. Julie Scott is an nurse and independent nurse prescriber with more than 20 years’ experience in the aesthetics industry and has worked with leading plastic surgeons in London. She now practises from her own Essex clinic, Facial Aesthetics. Qual: RGN, NIP

Providing added value I do understand that when practitioners start a practice in a saturated area it can be

Reproduced from Aesthetics | Volume 7/Issue 8 - July 2020

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JULY: THE SKINCARE ISSUE  

The July issue of Aesthetics explores topical treatments and skincare advice

JULY: THE SKINCARE ISSUE  

The July issue of Aesthetics explores topical treatments and skincare advice

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