Efficacy of laser hair removal in hidradenitis suppurativa: A systematic review and meta-analysis

OBJECTIVES

Hidradenitis suppurativa (HS) is a chronic inflammatory condition characterized by painful nodules, draining tunnels, and fibrotic scarring in intertriginous, hair-bearing areas. The pathogenesis involves follicular occlusion and subsequent rupture, leading to uncontrolled inflammation. Treatment options for HS are limited and lack universal effectiveness. Laser hair removal (LHR) has been explored as a potential treatment; however, the efficacy and appropriate laser modalities remain unclear. This systematic review examined the efficacy and adverse effects of LHR in HS.

METHODS

A comprehensive literature search was conducted from inception to September 2023 in Ovid MEDLINE, Ovid Embase, and The Cochrane Library (Wiley) with predefined inclusion and exclusion criteria, and a meta-analysis was conducted.

RESULTS

Ten studies were selected (n = 227 total patients) and included six randomized controlled trials, two nonrandomized experimental studies, and two case series. Various laser modalities, including long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) (n = 115), intense pulsed light (n = 18), Alexandrite (n = 54), intralesional 1064 nm diode (n = 20), and combined fractional CO2 and long-pulsed Nd:YAG laser (n = 20), consistently demonstrated significant improvement in HS disease severity, irrespective of the disease scoring method used. Minimal adverse effects (primarily mild pain and erythema) were reported. A meta-analysis of three studies utilizing long-pulsed Nd:YAG laser demonstrated a standardized mean difference in disease severity of -1.68 (95% confidence interval: -2.99; -0.37), favoring treatment with LHR for HS.

CONCLUSIONS

Hair follicles are key in HS pathogenesis and all included studies showed a significant improvement in HS disease severity after LHR regardless of the laser device used, likely related to hair follicle unit destruction. HS is a complex and heterogenous condition, and multiple disease scoring methods complicate outcome comparisons across studies. However, LHR, utilizing various techniques, is an effective treatment option for HS with minimal adverse effects.

Histological Assessment of the Effectiveness of Microneedling Device-Assisted Filler Delivery

BACKGROUND

Microneedling is used to enhance transcutaneous drug delivery. However, the extent to which microneedling devices impact filler delivery and whether this varies by filler type, microneedling device type, and treatment sequence is not known.

OBJECTIVE

To histologically assess and quantify the delivery of commonly used fillers through microneedling, using both a microneedling pen and a microneedling roller. In addition, the authors investigated whether there is a variation in filler delivery based on the sequence of microneedling in relation to topical filler application.

METHODS

Ex vivo human abdominal skin samples were subjected to microneedling pen or microneedling roller treatment. Black tissue marking ink, hyaluronic acid, poly-l-lactic acid, or undiluted calcium hydroxyapatite was topically applied before or immediately after microneedling treatment.

RESULTS

Histological evaluation revealed a notable presence of black ink within channels formed by both microneedling treatments (15.5%-98.1%), whereas there was limited presence of the various filler types tested (0%-6.6%) in all settings. Topical application before microneedling treatment led to relatively higher filler/ink deposition within the channels formed by the microneedling treatments compared with topical application after microneedling.

CONCLUSION

Transcutaneous delivery of fillers was not significantly helped by microneedling treatment, whereas the microneedling devices demonstrated effective delivery of an aqueous solution.

Advancing Dermatology Education and Care in Rwanda: The Impact of a New Academic Partnership

It is the realization of a long-dreamed aspiration to create a university that would advance global health delivery by training a new generation of global health leaders who are equipped to not just build, but sustain effective and equitable health systems.

1726 nm Lasers for the Treatment of Acne Vulgaris

The treatment of acne vulgaris traditionally consists of a combination of topical and oral medications. The use of lasers to treat this condition has been an area of increasing research, and several types have previously been used in the treatment of acne. New 1726 nm lasers specifically target the sebaceous gland, which is known to be pivotal in acne pathophysiology. This laser wavelength demonstrates substantial potential as a safe and effective therapeutic option for moderate to severe acne without the risks of systemic therapy. This paper reviews the 1726 nm lasers for acne vulgaris.

Novel 1726 nm laser demonstrates durable therapeutic outcomes and tolerability for moderate-to-severe acne across skin types

BACKGROUND

Traditional acne management with topical therapy, systemic antibiotics, hormonal agents, or oral isotretinoin requires compliance and may produce significant side effects. However, alternative treatments with lasers had failed to demonstrate durable clearance.

OBJECTIVE

To assess the tolerability and therapeutic outcomes of a novel 1726 nm laser treatment of moderate-to-severe acne across skin types.

METHODS

A prospective, open-label, single-arm, Investigational Device Exemption-approved, institutional review board-approved study of 104 subjects with moderate-to-severe facial acne and Fitzpatrick Skin Types ranging from II-to-VI was conducted. Subjects received 3 laser treatments at 3 (-1/+2)-week intervals.

RESULTS

Following final treatment, ≥50% reduction in active acne inflammatory lesions was 32.6% at 4-weeks follow-up, increasing further to 79.8% and 87.3% at 12 and 26-weeks, respectively. The percentage of subjects clear or almost clear increased from 0% at baseline to 9%, 36.0%, and 41.8% at 4-, 12-, and 26-weeks follow-up. No serious adverse events were observed related to device or protocol; treatments were well tolerated, requiring no anesthetic. Therapeutic outcomes and discomfort were similar across all skin types.

LIMITATIONS

Lack of control group.

CONCLUSIONS

The study findings demonstrate the novel 1726 nm laser is well tolerated with durable progressive posttreatment improvement to at least 26 weeks for moderate-to-severe acne across skin types.

Immunogenicity of DaxibotulinumtoxinA for Injection in Glabellar Lines

DaxibotulinumtoxinA-lanm for injection (DAXI), a novel botulinum toxin type A formulation, contains a purified 150-kD core neurotoxin (daxibotulinumtoxinA) and proprietary stabilizing peptide (RTP004), and is approved for glabellar line treatment. As with any biologic product, DAXI may potentially be immunogenic and elicit unwanted antibody formation, possibly resulting in partial or complete treatment failure. The immunogenicity of DAXI was assessed in 2 double-blind, placebo-controlled, single-dose studies and an open-label safety study of up to 3 repeat treatments. Of the 2737 evaluable patients, none developed neutralizing antibodies to daxibotulinumtoxinA and 0.8% developed treatment-related nonneutralizing anti-daxibotulinumtoxinA-binding antibodies. Of evaluable patients exposed to RTP004 with either DAXI or placebo, 1.3% developed treatment-related anti-RTP004-binding antibodies, which were mostly transient. No patient developed binding antibodies to both daxibotulinumtoxinA and RTP004. All patients with treatment-related binding antibodies to daxibotulinumtoxinA or RTP004 achieved a clinical response (none or mild glabellar line severity) at Week 4 following each DAXI treatment cycle. The duration of clinical response was not different between treatment cycles when antibodies were detected vs when they were absent. Although the analysis population was small compared to the number of patients likely to receive repeated treatment in clinical practice, these results suggest that DAXI administration at the approved glabellar lines dose has low immunogenic potential and that nonneutralizing antibodies to daxibotulinumtoxinA or RTP004 occur infrequently and often transiently, and have no impact on clinical efficacy, safety, or duration of action. Real-world data encompassing larger numbers of patients is needed to substantiate these results.

LEVEL OF EVIDENCE: 3

Bridging the Gap: Sustained Treatment Effect of Glabellar Lines With Twice-A-Year Treatment With DaxibotulinumtoxinA

BACKGROUND

To achieve natural-looking outcomes when treating dynamic lines with botulinum toxin (BoNT), retreatment must be timed such that the patient maintains a relatively constant aesthetic outcome. Although first-generation BoNT products require retreatment with 3- to 4-month frequency to avoid discontinuous correction, the average patient returns for treatment every 6 months, when these toxins have generally fully worn off.

OBJECTIVE

To discuss the number of days a typical patient treated with daxibotulinumtoxinA for injection (DAXI) or legacy BoNT products will spend undertreated or uncorrected in a given calendar year.

MATERIALS AND METHODS

Median time for maintaining glabellar lines in the "none" or "mild" severity range was compared for approved doses of onabotulinumtoxinA (ONA; 120 days) and DAXI (168 days).

RESULTS

The average patient treated with 40U of DAXI every 6 months can expect to be uncorrected (with "moderate" or "severe" glabellar lines) for 14.5 days between visits compared with 61.5 days for 20U of ONA.

CONCLUSION

An extended duration BoNT product can be expected to create greater consistency in aesthetic outcome and minimize the discontinuous correction commonly seen with first-generation BoNT products for patients treated twice a year, without requiring a change in patient behavior regarding visit frequency.

Laser-Assisted and Device-Assisted Filler Delivery: A Histologic Evaluation

BACKGROUND

Lasers and devices are used to enhance transcutaneous delivery of fillers. However, little has been published on the histologic findings of this form of laser/device-assisted delivery to determine the optimal devices and fillers.

OBJECTIVE

To objectively evaluate the histological effects of laser-assisted and device-assisted filler delivery.

METHODS

Ex vivo human abdominoplasty skin samples were treated with fractional CO 2 laser (ECO 2 , 120 μm tip, 120 mJ), fractional radiofrequency microneedling (FRMN, Genius, 1.5 mm, 20 mJ/pin), and microneedling (2.0 mm). Immediately after poly- l -lactic acid (PLLA), hyaluronic acid gel, calcium hydroxylapatite, and black tissue marking dye were topically applied. After treatment, biopsies were collected for histologic evaluation.

RESULTS

Histology revealed that PLLA and black dye were found in greatest abundance, hyaluronic acid was found to a lesser extent, and calcium hydroxylapatite was least found within channels created by fractional CO 2 laser. Microneedling was effective only at delivering black dye, whereas FRMN failed to show significant channel formation or delivery of the studied products.

CONCLUSION

Among the devices and fillers studied, fractional CO 2 laser and PLLA proved to be the most effective combination for laser/device-assisted filler delivery. Neither microneedling nor FRMN was effective as devices to enhance filler delivery.

Changes in melanocytic nevi treated with laser hair removal: A systematic review

BACKGROUND

Incidental treatment of melanocytic nevi during laser hair removal (LHR) has been noted to cause clinical and dermoscopic changes that may appear similar to findings seen in atypical or neoplastic melanocytic lesions. The rate and characteristics of these changes has not been well-studied.

OBJECTIVES

The objective of this review article is to assess the literature for reported changes in melanocytic nevi following LHR to guide clinical practice.

METHODS

PubMed was searched December 5, 2022 for articles evaluating changes in melanocytic nevi after LHR treatment using the following search terms: "nevi laser hair removal," "nevi diode," "nevi long pulse alexandrite," "nevi long pulse neodymium doped yttrium aluminum garnet," and "melanoma laser hair removal." All English language patient-based reports discussing incidental treatment of melanocytic nevi while undergoing LHR with a laser were eligible for inclusion, while reports of changes following hair removal with non-laser devices such as intense pulsed light were excluded. Studies evaluating non-melanocytic nevi such as Becker's nevus or nevus of Ota were excluded as were those evaluating the intentional ablation or removal of melanocytic lesions.

RESULTS

Ten relevant studies were included, consisting of seven case reports or series and three observational trials, two of which were prospective and one retrospective. Among the seven case reports or series there were a total of 11 patients, six of which had multiple affected nevi. Clinical and dermoscopic changes to nevi following LHR appear to be common in clinical practice, though not well studied. Clinical and dermoscopic changes have been noted to present as early as 15 days after treatment and persist to the maximum time of follow up at 3 years. Commonly reported changes include regression, decreased size, laser induced asymmetry, bleaching, darkening, and altered pattern on dermoscopy. Histologic changes include mild atypia, thermal damage, scar formation, and regression. Although some of the clinical and dermoscopic alterations may be concerning for malignancy, to our knowledge, there are no documented cases of malignant transformation of nevi following treatment with LHR.

LIMITATIONS

This study is limited by the low number of relevant reports and their generally small sample size, many of which is limited to single cases. Additionally, comparison of available data was limited by variable reporting of treatment regimens and outcomes.

CONCLUSIONS

Changes to nevi treated during LHR are not uncommon. Modifications to nevi may occur and look similar to changes seen in dysplastic or neoplastic melanocytic lesions. Notably, despite the widespread use of LHR since the first device was Food and Drug Administration approved in 1995, a time span of nearly three decades, there have been no reported cases of melanoma or severe dysplastic changes within treated nevi. However, dermatologists should be aware that morphologic and dermoscopic alterations can occur after LHR to prevent unnecessary surgical procedures. Although melanoma has not been reported to occur in nevi treated with LHR nor with any other laser exposures, further long-term data is needed to fully elucidate this concern. Optimally, nevi should be examined by a dermatologist before LHR to determine a baseline clinical and dermoscopic morphology. If there is concern for potential atypia, laser should be avoided over such nevi to avoid confusion at future follow up visits.

Clinical Immunogenicity of DaxibotulinumtoxinA for Injection in Glabellar Lines: Pooled Data from the SAKURA Phase 3 Trials

DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin type A product containing daxibotulinumtoxinA with a stabilizing excipient peptide (RTP004). DAXI immunogenicity was assessed in three phase 3 glabellar line studies (two placebo-controlled, single-dose studies and an open-label repeat-dose safety study). Binding antibodies to daxibotulinumtoxinA and RTP004 were detected by validated ELISAs. Samples positive for daxibotulinumtoxinA-binding antibodies were evaluated further for titer and neutralizing antibodies by mouse protection assay. Overall, 2786 subjects received DAXI and 2823 subjects were exposed to RTP004 as DAXI (n = 2786) or placebo (n = 37). Treatment-related anti-daxibotulinumtoxinA binding antibodies were detected in 21 of 2737 evaluable subjects (0.8%). No subject developed neutralizing antibodies. Treatment-related anti-RTP004 binding antibodies were detected in 35 (1.3%) of 2772 evaluable subjects. Binding antibodies were generally transient, of low titer (<1:200), and no subject had binding antibodies to both daxibotulinumtoxinA and RTP004. All subjects with treatment-induced binding antibodies to daxibotulinumtoxinA or RTP004 achieved none or mild glabellar line severity at Week 4 following each DAXI cycle, indicating no impact on DAXI efficacy. No subjects with binding antibodies to daxibotulinumtoxinA or RTP004 reported immune-related adverse events. This evaluation of anti-drug antibody formation with DAXI shows low rates of antibody formation to both daxibotulinumtoxinA and RTP004.

Evidence-Based Clinical Practice Guidelines for Laser-Assisted Drug Delivery

Importance

Laser-assisted drug delivery (LADD) is used for various medical and cosmetic applications. However, there is insufficient evidence-based guidance to assist clinicians performing LADD.

Objective

To develop recommendations for the safe and effective use of LADD.

Evidence Review

A systematic literature review of Cochrane Central Register of Controlled Trials, Embase, and MEDLINE was conducted in December 2019 to identify publications reporting research on LADD. A multidisciplinary panel was convened to draft recommendations informed by the systematic review; they were refined through 2 rounds of Delphi survey, 2 consensus meetings, and iterative review by all panelists until unanimous consensus was achieved.

Findings

Of the 48 published studies of ablative fractional LADD that met inclusion criteria, 4 were cosmetic studies; 21, oncologic; and 23, medical (not cosmetic/oncologic), and 6 publications of nonablative fractional LADD were included at the request of the expert panel, producing a total of 54 studies. Thirty-four studies (63.0%) were deemed to have low risk of bias, 17 studies (31.5%) had moderate risk, and 3 (5.5%) had serious risk. The key findings that informed the guidelines developed by the expert panel were as follows: LADD is safe in adults and adolescents (≥12 years) with all Fitzpatrick skin types and in patients with immunosuppression; it is an effective treatment for actinic keratosis, cutaneous squamous cell carcinoma in situ, actinic cheilitis, hypertrophic scars, and keloids; it is useful for epidermal and dermal analgesia; drug delivery may be increased through the application of heat, pressure, or occlusion, or by using an aqueous drug solution; laser settings should be selected to ensure that channel diameter is greater than the delivered molecule; antibiotic prophylaxis is not recommended, except with impaired wound healing; antiviral prophylaxis is recommended when treating the face and genitalia; and antifungal prophylaxis is not recommended. The guideline's 15 recommendations address 5 areas of LADD use: (I) indications and contraindications; (II) parameters to report; (III) optimization of drug delivery; (IV) safety considerations; and (V) prophylaxis for bacterial, viral, and fungal infections.

Conclusions and Relevance

This systematic review and Delphi consensus approach culminated in an evidence-based clinical practice guideline for safe and effective use of LADD in a variety of applications. Future research will further improve our understanding of this novel treatment technique.

Review of Lasers and Energy-Based Devices for Skin Rejuvenation and Scar Treatment With Histologic Correlations

BACKGROUND

Lasers and energy-based devices (EBD) are popular treatments for skin rejuvenation and resurfacing. Achieving desired outcomes and avoiding complications require understanding the effects of these devices at a histologic level. Currently, no comprehensive review summarizing the histologic effects of laser and energy-based treatments exists.

OBJECTIVE

To describe how lasers and EBD alter skin histology and improve the overall understanding of these devices.

MATERIALS AND METHODS

A PubMed search was conducted for studies with histologic analysis of fractional picosecond laser, fractional radiofrequency microneedling, nonablative lasers, and ablative lasers.

RESULTS

Fractional picosecond lasers induce intraepidermal and/or dermal vacuoles from laser-induced optical breakdown. Fractional radiofrequency microneedling delivers thermal energy to the dermis while sparing the epidermis, making it safer for patients with darker skin phototypes. Fractional nonablative lasers induce conical zones of coagulation of the epidermis and upper dermis. Ablative lasers vaporize the stratum corneum down to the dermis. Traditional ablative lasers cause diffuse vaporization while fractional ablative lasers generate columns of tissue ablation.

CONCLUSION

Lasers and EBD are effective for skin resurfacing and rejuvenation and have different mechanisms with disparate targets in the skin. Safe and effective use of devices requires understanding the histologic laser-tissue interaction.

Use of Neuromuscular Electrical Stimulation for Abdominal and Quadriceps Muscle Strengthening: A Randomized Controlled Trial

BACKGROUND

Radiographic imaging has demonstrated muscle hypertrophy after treatment with noninvasive body contouring devices that target skeletal muscles.

OBJECTIVE

This pilot study sought to evaluate whether increased muscle mass translated to improved functional strength and endurance.

METHODS

A prospective, single-center, randomized open-label controlled study included 26 subjects randomized into 3 groups: 2 treatment groups and 1 control group. Both treatment groups received 4 neuromuscular electrical stimulation (NMES) treatments over a 2-week period. Muscle performance testing was conducted at baseline and 2-week and 4-week posttreatment. Anthropometric measurements were assessed at baseline and at 4-week posttreatment. Study participants completed subject satisfaction surveys and a personal experience assessment.

RESULTS

Treatment with NMES resulted in statistically significant improvements in abdominal and quadriceps strength and endurance from baseline through 4-week posttreatment. Mean waist circumference decreased and quadriceps circumference increased, both nonsignificantly. Subject satisfaction regarding abdominal and quadriceps strength was reported as "satisfied or very satisfied" in 89% and 92% at 4-week and 8-week posttreatment, respectively.

CONCLUSION

Treatment of the abdomen and quadriceps with NMES leads to significant improvements in muscular strength and endurance.

1,550 nm Erbium-Doped and 1,927 nm Thulium Nonablative Fractional Laser System: Best Practices and Treatment Setting Recommendations

BACKGROUND

The Fraxel Dual laser system (Solta Medical, Inc., Bothell, WA) contains a 1,550 and 1,927 nm wavelength single handpiece with different indications for each wavelength.

OBJECTIVE

To discuss treatment setting recommendations and best practices for select on-label and investigational applications of the 1,550 and 1,927 nm dual laser system.

MATERIALS AND METHODS

Eight board-certified dermatologists with 10 or more years of experience with the 1,550 and 1,927 nm laser system completed an online survey about their clinical experience with the system and then participated in a roundtable to share clinical perspectives and best practices for using the laser system.

RESULTS

For all Fitzpatrick skin types, treatment recommendations were described for selected approved indications for the 1,550 and 1,927 nm laser system, including both lasers in combination. Treatment recommendations were also reached for investigational applications with the 1,550 nm laser and 1,927 nm laser. Best practices for using the lasers during the treatment session to achieve optimal outcomes and decrease the post-treatment recovery time were compiled.

CONCLUSION

The 1,550 and 1,927 nm dual laser system is effective for a wide range of aesthetic and therapeutic applications, on and off the face and across all Fitzpatrick skin types.

Actinic Keratosis Color and Its Associations: A Retrospective Photographic, Dermoscopic, and Histologic Evaluation

BACKGROUND AND OBJECTIVE

Actinic keratoses (AKs) have been described with varying color and morphology; however, no reports have demonstrated associations between color, vasculature, and inflammation. In this retrospective study, we analyze the clinical, dermoscopic, and histopathologic features of AKs to elucidate this relationship.

METHODS

A retrospective search for patients diagnosed with AK between January 2018 and October 2019 was performed. Clinical and dermoscopic photographs and pathology slides for all included subjects were reviewed.

RESULTS

Forty-nine images and histopathology slides were analyzed. Dermoscopy of white AKs demonstrated scale and absence of erythema with corresponding absence of inflammation on histopathology. Dermoscopy of brown AKs revealed pseudonetwork, absent scale, and a variable vessel pattern with pigment incontinence and absence of inflammation on histopathology. Red AKs had a distinct polymorphous vessel pattern and presence of erythema on dermoscopy. On histopathology, about half of samples showed increased vascularity and variable inflammation. Pink AK dermoscopy revealed a presence of erythema with corresponding presence of inflammation on histopathology.

CONCLUSION

This report adds to our understanding of AKs and confirms that, in general, the pinker or redder the AK, the more prominent the inflammatory infiltrate and vasculature, respectively. Dermatologists should continue to use their diagnostic skills to successfully diagnose and triage AKs.

The Second of Two One-Year, Multicenter, Open-Label, Repeat-Dose, Phase II Safety Studies of PrabotulinumtoxinA for the Treatment of Moderate to Severe Glabellar Lines in Adult Patients

BACKGROUND

PrabotulinumtoxinA is a 900-kDa botulinum toxin type A produced by Clostridium botulinum.

OBJECTIVES

The authors sought to investigate the safety of prabotulinumtoxinA for treatment of glabellar lines.

METHODS

This was a multicenter, open-label, repeat-dose, 1-year phase II safety study. Adults with moderate to severe glabellar lines at maximum frown, as independently assessed by both investigator and patient on the validated 4-point photonumeric Glabellar Line Scale (0 = no lines, 1 = mild, 2 = moderate, 3 = severe), were enrolled. On day 0, patients received an initial treatment (IT) of 20 U prabotulinumtoxinA (4 U/0.1 mL final vacuum-dried formulation injected into 5 glabellar sites). On and after day 90, patients received a repeat treatment (RT) if their Glabellar Line Scale score was ≥2 at maximum frown by investigator assessment. Safety outcomes were evaluated throughout the study.

RESULTS

The 570 study patients received a median total dose of 60 U, that is, 3 treatments. Sixty-one patients (10.7%) experienced adverse events (AEs) assessed as possibly study drug related; 6.5% experienced study drug-related AEs after the IT. With each RT, progressively lower percentages of patients experienced study drug-related AEs. Eight patients (1.4%) experienced study drug-related AEs of special interest: 5 experienced eyelid ptosis (0.9%), 3 eyebrow ptosis (0.5%), 1 blepharospasm (0.2%), and 1 blurred vision (0.2%). Seven patients (1.2%) experienced serious AEs, but none were study drug related. A total of 4060 serum samples were tested for antibotulinum toxin antibodies; no seroconversion was observed.

CONCLUSIONS

The safety of RTs of 20 U of prabotulinumtoxinA for moderate to severe glabellar lines was confirmed in this second phase II study based on a broad range of outcomes.

LEVEL OF EVIDENCE: 2

Rates of Vascular Occlusion Associated With Using Needles vs Cannulas for Filler Injection

Importance

Soft-tissue augmentation with skin fillers can be delivered with needles or microcannulas, but unwanted vascular occlusions are possible.

Objective

To determine whether filler-associated vascular occlusion events of the face occur more often with injections performed with needles than with microcannulas.

Design, Setting, and Participants

This retrospective cohort study included a random sample of board-certified dermatologists deemed eligible based on membership in relevant professional societies and attendance at relevant national professional meetings. Participants completed detailed forms in which they could enter deidentified data and volume statistics pertaining to patients undergoing filler procedures in their practices. Data were collected from August 2018 to August 2019.

Exposures

Injectable fillers approved by the US Food and Drug Administration delivered via needles or microcannulas.

Main Outcomes and Measures

The primary outcome measure was intravascular occlusion. Occlusion events were graded by severity (no sequelae, scar, and ocular injury or blindness).

Results

A total of 370 dermatologists (mean [SD] years in practice, 22.3 [11.1] years) participated and reported 1.7 million syringes injected. The risk of occlusion with any particular filler type using needle or cannula never exceeded 1 per 5000 syringes injected. Overall, 1 occlusion per 6410 per 1-mL syringe injections was observed with needles and 1 per 40 882 with cannulas (P < .001). Of the 370 participants, 106 (28.6%) reported at least 1 occlusion. Multivariate analysis found that injections with cannula had 77.1% lower odds of occlusion compared with needle injections. Participants injecting fillers for more than 5 years had 70.7% lower odds of occlusion than those who were less experienced. For each additional injection per week, the odds of occlusion decreased by 1%, and 85% of occlusions had no long-term sequelae. Nasolabial folds and lips were most likely to be occluded, with mean severity level of occlusions highest at the glabella.

Conclusions and Relevance

In this cohort study, filler injections with either needles or cannulas were associated with a very low risk of intravascular occlusion events. Moreover, the vast majority of such events were minor and resolved without scar or other injury. Injections with microcannulas were less often associated with occlusion events than injections with needles. Occlusion risk per syringe appeared decreased after the first few years of clinical practice and was also lower among those who more frequently inject fillers. Whether a needle or cannula is most appropriate for injection may depend on patient factors, anatomic site, and the type of defect being treated.

A pilot study evaluating the efficacy and tolerability of a comprehensive, hydrating topical antioxidant developed specifically for men

Introduction

There is growing interest in skincare products designed for men. This pilot study evaluated the efficacy and tolerability of a comprehensive antioxidant product in men.

Methods

This 12‐week study evaluated improvements from baseline in erythema, lines/wrinkles, skin tone, texture, brightness, dryness/flaking and pores (6‐point scale), global improvements (5‐point scale), and sebum levels following daily application in males with mild to moderate photodamaged skin. Subject self‐assessments and adverse events (AEs) were captured.

Results

Twenty‐two subjects completed the study. Early mean percent improvements from baseline were demonstrated in all categories at week 4 with visible improvements in skin tone (29%; p = .0001) and pores (28%; p < .0001). Reductions in skin surface sebum levels (forehead region) from baseline were demonstrated at 8 (p < .0001) and 12 (p < .0003) weeks. Ninety‐six percent of subjects reported overall visible improvement of their skin and that the study product calmed/soothed skin, reducing redness and irritation after shaving. One subject reported mild dryness.

Conclusion

Once daily application of a comprehensive topical antioxidant designed for men led to significant improvements in skin appearance, substantial reductions in skin surface sebum levels, and was well tolerated with a high level of subject satisfaction over 12 weeks.

Cutaneous Photoaging: A Notable Pattern of Distribution of Lentigines on the Face

Importance: Facial lentigines are a common patient complaint encountered in general and cosmetic dermatology practices. Lentigines are a marker of photoaging and understanding their distribution will provide insight into the aging process in order to better counsel patients. Objectives: To compare the relative distribution of lentigines in facial cosmetic subunits. Methods: We reviewed clinical photographs of patients receiving Alexandrite laser treatment for facial lentigines during the time period 11/1/2017-12/1/2018. Individual lentigines were plotted for each patient into one of 21 aesthetic units. A "heat map" was created to compare the relative density of these lesions. Results: Grouped peripheral cosmetic subunits contained more lentigines compared to grouped central cosmetic units. The mean number of lentigines in the central units was 0.60 and in the peripheral units was 0.85. This finding was statistically significant with a p value of 0.0001. J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.5193.

Microneedling as an adjuvant to topical therapies for melasma: A systematic review and meta-analysis

BACKGROUND

Microneedling as an adjuvant to topical medications has shown promising but variable results in the treatment of melasma.

OBJECTIVE

To conduct a systematic review and meta-analysis on the efficacy of microneedling as an adjuvant to topical therapies for the treatment of melasma.

METHODS

This study followed PRISMA guidelines. All comparative, prospective studies on the use of topical interventions with microneedling for the treatment of melasma were included. Studies involving radiofrequency microneedling were excluded.

RESULTS

Twelve eligible studies comprising 459 patients from 7 different countries were included. Topical therapies included topical tranexamic acid, vitamin C, platelet-rich plasma, non-hydroquinone-based depigmentation serums, and hydroquinone-based depigmenting agents. Topical therapy with microneedling improved melasma severity with a large effect (standardized mean difference >0.8) beyond 8 weeks, with best results seen at 12 weeks. Compared to topical therapy alone, topical therapy with microneedling resulted in an additional improvement in melasma severity with a moderate effect at 8 weeks and a large effect at 12-16 weeks. Microneedling was well tolerated across studies, with no serious adverse events reported.

LIMITATIONS

Heterogeneity in study designs did not allow for a comparison of the efficacy of various topical therapies with microneedling.

CONCLUSION

Microneedling is useful adjuvant to topical therapies for the treatment of melasma.

Needle Manufacturing, Quality Control, and Optimization for Patient Comfort

INTRODUCTION

There is an increasing rise of cosmetic injectables. We sought to understand the manufacturing, quality control process, and needle selection of hypodermic needles for fillers.

OBJECTIVE

To understand the process of manufacturing and quality control of hypodermic needles and the relevance to an aesthetic clinician.

METHODS

We conducted a search of the internet and contacted medical device companies to understand the manufacturing process. We then collaborated with the Executive director of global pharmaceutical technology from Abbvie as well as the packaging and device engineer at Galderma and summarized our findings. Finally, we reviewed the literature and summarized existing recommendations on techniques to minimize pain related to injection.

RESULTS

Hypodermic needles undergo an extensive manufacturing and regulatory process. Many considerations are taken into account in needle manufacturing as well as the selection process with commercially available hyaluronic acid filler products. Needle manufacturers are held to universal standards though the International Organization for Standardization (ISO). Filler companies perform their own testing to evaluate suitability of needles for their product including leakage force, penetration force, extrusion force, etc. Finally, parameters such as needle length, needle diameter, and wall thickness are considered for selection of needle/hub with individual filler viscosity.

CONCLUSION

There is extensive consideration that goes into needle manufacturing, quality control, and optimization for hyaluronic acid filler. Understanding the technical process helps inform the clinician and guide patient care for maximum comfort. J Drugs Dermatol. 2021;20(1):44-48. doi:10.36849/JDD.5591.

A 12-Week, Prospective, Non-Comparative, Non-Randomized Study of Magnetic Muscle Stimulation for Improvement of Body Satisfaction With the Abdomen and Buttocks

Background and Objective

Magnetic muscle stimulation (MMS) is a relatively new energy‐based technology that provides a non‐invasive option for body contouring through stimulation and toning of underlying skeletal muscles. This study was conducted to examine the safety, efficacy, and body satisfaction scores of MMS using a CoolToneTM prototype for the aesthetic improvement of abdominal and buttock contour.

Study Design/Materials and Methods

This was a prospective, non‐comparative, non‐randomized, 12‐week, multicenter study. Male and female participants aged 22‐65 years received 4 MMS treatment sessions to the abdomen and/or buttocks. Body Satisfaction Questionnaire (BSQ) scores for abdomen and/or buttocks were assessed at baseline, immediately post final treatment, at 4 weeks (primary endpoint), and 12 weeks post final treatment. Subject‐rated Global Aesthetic Improvement Scale (SGAIS) was assessed at 4 weeks post final treatment (secondary endpoint), and 12 weeks post final treatment. Additional efficacy assessment included abdominal circumference obtained by 3D imaging at baseline, immediately post final treatment, and at 4 and 12 weeks post final treatment. A Subject Experience Questionnaire (SEQ) was used to assess treatment satisfaction and perspectives at 4 weeks and 12 weeks post final treatment. Adverse events (AEs) were monitored throughout the study.

Results

A total of 110 participants were recruited, who were 75% female, 80% Caucasian (mostly non‐Hispanic), average age of 39.5 years (range 22–59) with an average body mass index (BMI) of 23.3 kg/m2 (range 18–29.9). At the 4‐week post final treatment visit, the average BSQ score for participants receiving abdominal treatment (n = 93) was significantly improved with a 5.1 average increase in total score from baseline (possible score range 10–50) and by a 5.5 average increase from baseline for participants receiving buttocks treatment (n = 32) (p < 0.05). At 4 weeks post final treatment, the proportion of participants with SGAIS scores >“Improved” was 68.1% for participants receiving treatment of the abdomen (n = 94), and 81.8% for those receiving buttocks treatment (n = 33). The mean total decrease from baseline in waist circumference was significant at all time points. At the 12‐week post final treatment visit, SEQ data revealed that a majority of participants were “Satisfied” or “Very Satisfied” with overall treatment results and “Agreed” or “Strongly Agreed” that they were motivated to maintain results either by working out or by additional treatment. A total of 6 AEs related to the device and/or treatment were reported, which resolved spontaneously during the study.

Conclusion

Treatment of the abdomen and/or buttocks with MMS was well‐tolerated and demonstrated significant improvement in aesthetic appearance through the 12‐week post final treatment study duration. As a stand‐alone treatment, MMS expands the range of options for individualized treatment planning for patients seeking abdominal and/or gluteal muscle toning. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals, Inc.

Plume Effect of Fractional Radiofrequency Verus Laser Resurfacing: Considerations in the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic requires us all to re-evaluate aesthetic practices to ensure optimal patient safety during elective procedures. Specifically, energy-based devices and lasers require special consideration, as they may emit plume which has been shown to contain tissue debris and aerosolized biological materials. Prior studies have shown transmission of viruses and bacteria via plume (i.e., HIV and papillomavirus). The purpose of this study was to evaluate plume characteristics of the Er:YAG resurfacing laser (Sciton; Palo Alto, CA) and compare it to the Morpheus8 fractional radiofrequency device (InMode; Lake Forest, CA).

METHODS

Five patients who underwent aesthetic resurfacing and/or skin tightening of the face and neck were treated with the Er:YAG (Sciton Joule, Palo Alto, CA) and/or fractional radiofrequency (Morpheus8, Lake Forest, CA) between April 1 and May 11, 2020. Data collected included patient demographics, past medical history, treatment parameters, adverse events, particle counter data, as well as high magnification video equiptment. Patients were evaluated during treatment with a calibrated particle meter (PCE; Jupiter, FL). The particle meter was used at a consistent focal distance (6-12 inches) to sample the surrounding environment during treatment at 2.83 L/min to a counting efficiency of 50% at 0.3 µm and 100% at >0.45 µm. Recordings were obtained with and without a smoke evacuator.

RESULTS

Of our cohort (n = 5), average age was 58 years old (STD ±7.2). Average Fitzpatrick type was between 2 and 3. Two patients received Er:YAG fractional resurfacing in addition to fractional radiofrequency during the same treatment session. Two patients had fractional radiofrequency only, and one patient had laser treatment with the Er:YAG only. There were no adverse events recorded. The particle counter demonstrated ambient baseline particles/second (pps) at 8 (STD ±6). During fractional radiofrequency treatment at 1-mm depth, the mean recording was 8 pps (STD ±8). At the more superficial depth of 0.5 mm, recordings showed 10 pps (STD ±6). The Er:YAG laser resurfacing laser had mean readings of 44 pps (STD ±11). When the particle sizes were broken down by size, the fractional radiofrequency device had overall smaller particle sizes with a count of 251 for 0.3 µm (STD ±147) compared with Er:YAG laser with a count of 112 for 0.3 µm (STD ±84). The fractional radiofrequency did not appear to emit particles >5 µm throughout the treatment, however, the Er:YAG laser consistently recorded majority of particles in the range of 5-10 µm. The addition of the smoke evacuator demonstrated a 50% reduction in both particles per second recorded as well as all particle sizes.

CONCLUSION

Re-evaluation of the plume effect from aesthetic devices has become important during the COVID-19 pandemic. Further studies are required to characterize viability of COVID-19 viability and transmissibility in plume specimens. Based on this pilot study, we recommend that devices that generate little to no plume such as fractional radiofrequency devices be used in Phase I reopening of practice while devices that generate a visible plume such as Er:YAG laser resurfacing devices be avoided and only used with appropriate personal protective equipment in addition to a smoke evacuator in Phase IV reopening.

Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm

Background and Objectives

There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose.

Materials and Methods

A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists.

Results

Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement.

Conclusion

A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.

Oxymetazoline and Energy-Based Therapy in Patients with Rosacea: Evaluation of the Safety and Tolerability in an Open-Label, Interventional Study

Background and Objectives

The objectives of this study were to evaluate the safety, tolerability, and efficacy of oxymetazoline hydrochloride cream, 1% (oxymetazoline) when used as an adjunctive treatment with energy‐based therapy for patients with moderate to severe facial erythema associated with rosacea.

Study Design/Materials and Methods

In this Phase 4, multicenter, interventional, open‐label study, eligible patients received one of four energy‐based therapies (potassium titanyl phosphate laser, intense pulsed light therapy, pulsed‐dye laser Vbeam Perfecta, or pulsed‐dye laser Cynergy) on day 1 and day 29 and once‐daily application of oxymetazoline on days 3 through 27 and days 31 through 56. Improvement from baseline in Clinician Erythema Assessment (CEA) score, patient satisfaction measures, incidence of treatment‐emergent adverse events (TEAEs), and worsening from baseline on dermal tolerability assessments and the Clinician Telangiectasia Assessment (CTA) were assessed. Data were summarized using descriptive statistics.

Results

A total of 46 patients (mean age, 51.1 years; 78.3% female) enrolled in this study. Similar numbers of patients received each of the energy‐based therapies in addition to oxymetazoline. All patients demonstrated an improvement from baseline in CEA during the study with 39 of 43 evaluable patients (90.7%) demonstrating an improvement 6 hours posttreatment on day 56. Most patients were satisfied or very satisfied with treatment at the end of the study. All TEAEs were mild or moderate in severity. Some patients experienced worsening in dermal tolerability assessment symptoms (range: 4–21 patients; 8.7–45.7%). Worsening in CEA and CTA were each reported by three patients (6.5%) at any time during the study.

Conclusions

Treatment with oxymetazoline as adjunctive therapy with energy‐based therapy was safe, well tolerated, and reduced facial erythema in patients with moderate to severe persistent facial erythema associated with rosacea. Lasers Surg. Med. © 2020 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC

A PATH TO RESUME AESTHETIC CARE EXECUTIVE SUMMARY OF PROJECT AesCert™ GUIDANCE SUPPLEMENT: PRACTICAL CONSIDERATIONS FOR AESTHETIC MEDICINE PROFESSIONALS SUPPORTING CLINIC PREPAREDNESS IN RESPONSE TO THE SARS-CoV-2 OUTBREAK

This Project AesCert™ Guidance Supplement ("Guidance Supplement") was developed in partnership with a multi-disciplinary panel of board-certified physician and doctoral experts in the fields of Infectious Disease, Immunology, Public Health Policy, Dermatology, Facial Plastic Surgery and Plastic Surgery. The Guidance Supplement is intended to provide aesthetic medicine physicians and their staffs with a practical guide to safety considerations to support clinic preparedness for patients seeking non-surgical aesthetic treatments and procedures following the return-to-work phase of the COVID-19 pandemic, once such activity is permitted by applicable law. Many federal, state and local governmental authorities, public health agencies and professional medical societies have promulgated COVID-19 orders and advisories applicable to health care practitioners. The Guidance Supplement is intended to provide aesthetic physicians and their staffs with an additional set of practical considerations for delivering aesthetic care safely and generally conducting business responsibly in the new world of COVID-19. Aesthetic providers will face new and unique challenges as government stay-at-home orders and related commercial limitations are eased, and the U.S. economy reopens and healthcare systems transition from providing only urgent and other essential treatment to resuming routine care and elective procedures and services. The medical aesthetic specialties will therefore wish to resume practice in order to ensure high quality, expert care is available, and importantly to help promote patients' positive self-image and sense of well-being following a lengthy and stressful period of quarantine. In a number of areas, this Guidance Supplement exceeds traditional aesthetic office safety precautions, recognizing reduced tolerance in an elective treatment environment for any risk associated with COVID-19's highly variable presentation and unpredictable course. The disease has placed a disturbing number of young, otherwise healthy patients in extremis with severe respiratory and renal failure, stroke, pericarditis, neurologic deficits and other suddenly life-threatening complications, in addition to its pernicious effects on those with pre-existing morbidities and advanced age. Accordingly, the Guidance Supplement seeks to establish an elevated safety profile for providing patient care while reducing, to the greatest extent reasonably possible, the risk of infectious processes to both patients and providers. While the Guidance Supplement cannot foreclose the risk of infection, nor serve to establish or modify any standards of care, it does offer actionable risk-mitigation considerations for general office comportment and for certain non-surgical procedures typically performed in aesthetic medical settings. It is axiomatic that all such considerations are necessarily subject to the ultimate judgment of each individual healthcare professional based on patient situation, procedure details, office environment, staffing constraints, equipment and testing availability, and local legal status and public health conditions.

In vitro and in vivo evaluation of a moisture treatment cream containing three critical elements of natural skin moisturization

Objectives

To evaluate skin barrier and hydration effects of a new rebalancing moisture treatment (TRMT) and to assess efficacy and tolerability in subjects with photodamaged skin.

Methods

In an epidermal skin model, tissues (n = 5/group) were topically treated with 25 µL of TRMT, 25 µL of a market‐leading moisturizer (MLM), or untreated for 60 minutes. Hydration was measured at 0, 15, and 30 minutes. Tissues were harvested for gene expression analysis of markers associated with skin barrier and hydration: Claudin (CLD), Aquaporin (AQP), Hyaluronic Acid Syntheses (HAS), and Hyaluronidase (HYAL). A clinical study evaluated twice‐daily application of TRMT, assessing changes in fine lines/wrinkles, brightness, texture, erythema, and tolerability from baseline through week 8. Hydration was measured using electrical impedance.

Results

TRMT and MLM demonstrated significant increases in hydration vs untreated tissue at each timepoint (P < .005), with greater hydration effects observed for TRMT vs MLM. TRMT‐treated tissues demonstrated greater expression of CLD, AQP, and HA, and reduced expression of HYAL vs untreated and MLM‐treated tissues. Twice‐daily application of TRMT demonstrated significant improvements at 2 weeks in fine lines/wrinkles (P < .001), brightness (P < .0001), texture (P < .0004), and hydration (P < .004). At 8 weeks, statistically significant improvements were achieved in all categories.

Conclusion

In an epidermal skin model, TRMT demonstrated significant increases in hydration, greater hydration effects, and expression of key markers associated with skin barrier and hydration vs a MLM. Twice‐daily application of TRMT was well tolerated and resulted in early, significant improvements in hydration and visible improvements in skin brightness, texture, fine lines/wrinkles, and erythema at 8 weeks.

Delayed-Onset Nodules to Differentially Crosslinked Hyaluronic Acids: Comparative Incidence and Risk Assessment

BACKGROUND

Robust and long-term data on true incidence of delayed-onset nodules and immune tolerance of hyaluronic acid (HA) fillers are lacking.

OBJECTIVE

To characterize the incidence of delayed nodules in Vycross (VYC) HA fillers compared with previously reported FDA and non-FDA data of all HA fillers.

METHODS AND MATERIALS

The incidence of delayed nodules in all patients who had received VYC fillers in a 12-month period was assessed through a retrospective chart review. Nodule incidence for currently approved nonanimal-stabilized hyaluronic acid (NASHA) fillers was assessed using the FDA Summary of Safety and Effectiveness Data.

RESULTS

Overall, 1,029 patients received 1,250 VYC filler treatments. Five patients developed delayed nodules to VOB, with an incidence of 1.0% per patient and 0.8% per syringe. No nodules were observed in patients who received VLR or VOL. All nodules were treated successfully using a combination of intralesional triamcinolone and hyaluronidase. Compared with other currently approved NASHA fillers, VOB is associated with a higher incidence of nodule formation.

CONCLUSION

The introduction of VYC HAs has introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.

Self-reported Patient Motivations for Seeking Cosmetic Procedures

Importance

Despite the growing popularity of cosmetic procedures, the sociocultural and quality-of-life factors that motivate patients to undergo such procedures are not well understood.

Objective

To estimate the relative importance of factors that motivate patients to seek minimally invasive cosmetic procedures.

Design, Setting, and Participants

This prospective, multicenter observational study was performed at 2 academic and 11 private dermatology practice sites that represented all US geographic regions. Adult patients presenting for cosmetic consultation or treatment from December 4, 2016, through August 9, 2017, were eligible for participation.

Exposures

Participants completed a survey instrument based on a recently developed subjective framework of motivations and a demographic questionnaire.

Main Outcomes and Measures

Primary outcomes were the self-reported most common motivations in each quality-of-life category. Secondary outcomes were other frequently reported motivations and those associated with specific procedures.

Results

Of 529 eligible patients, 511 agreed to participate, were enrolled, and completed the survey. Typical respondents were female (440 [86.1%]), 45 years or older (286 [56.0%]), white (386 [75.5%]), and college educated (469 [91.8%]) and had previously received at least 2 cosmetic procedures (270 [52.8%]). Apart from motivations pertaining to aesthetic appearance, including the desire for beautiful skin and a youthful, attractive appearance, motives related to physical health, such as preventing worsening of condition or symptoms (253 of 475 [53.3%]), and psychosocial well-being, such as the desire to feel happier and more confident or improve total quality of life (314 of 467 [67.2%]), treat oneself or celebrate (284 of 463 [61.3%]), and look good professionally (261 of 476 [54.8%]) were commonly reported. Motivations related to cost and convenience were rated as less important (68 of 483 [14.1%]). Most motivations were internally generated, designed to please the patients and not others, with patients making the decision to undergo cosmetic procedures themselves and spouses seldom being influential. Patients younger than 45 years were more likely to undertake procedures to prevent aging (54 of 212 [25.5%] vs 42 of 286 [14.7%] among patients ≥45 years; P < .001). Patients seeking certain procedures, such as body contouring (19 of 22 [86.4%]), acne scar treatment (36 of 42 [85.7%]), and tattoo removal (8 of 11 [72.7%]), were more likely to report psychological and emotional motivations.

Conclusions and Relevance

This initial prospective, multicenter study comprehensively assessed why patients seek minimally invasive cosmetic procedures. Common reasons included emotional, psychological, and practical motivations in addition to the desire to enhance physical appearance. Differences relative to patient age and procedures sought may need further exploration.

Treating Acne With Topical Antibiotics: Current Obstacles and the Introduction of Topical Minocycline as a New Treatment Option

Oral antibiotics are well established treatments for acne vulgaris but are associated with undesirable side effects. Topical antibiotics offer an improved safety profile but have led to an alarming rise in worldwide P. acnes resistance. Fortunately, a new class of topical minocycline products has been developed for the treatment of acne and rosacea that decreases the risk for antibiotic resistance while maintaining safety and efficacy. Recent clinical studies have demonstrated that a hydrophilic minocycline gel (BPX-01) and a lipophilic minocycline foam (FMX101) both reduced acne lesion counts with negligible systemic absorption. Head-to-head studies have yet to be completed, but the hydrophilic gel studies reported greater treatment efficacy than the lipophilic foam studies. J Drugs Dermatol. 2019;18(3):240-244.