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Cutaneous Drug Eruptions
Skin Cancer Prevention
Skin Disease in HIV
In 2009, the American Society for Aesthetic Plastic Surgery revealed that in spite of the recession and decrease in personal financial security, Americans spent approximately $10.5 billion dollars on cosmetic procedures; men accounted for nearly 10% of the estimated 10 million procedures.1 Surgical interventions included liposuction, breast augmentation, eyelid surgery, and breast reduction, and popular nonsurgical interventions included botulinum toxin product injections, laser hair removal, and microdermabrasions. The antiaging field encompasses a wide array of cosmetic and surgical interventions aimed at changing both physical wellness and outward appearance, including cosmetic dermatology.
One of the fastest-growing options is injectable dermal fillers, which offer the advantage of quick, relatively inexpensive, and increasingly longer-lasting results for facial wrinkles and deeper folds. Dermal fillers have become the first-line treatment for nonsurgical options, as they are safe, efficient, and result in improvements for age- and photodamaged areas of the face with minimal adverse effects. NPs need to understand the differences between the types of fillers and their use, as many supportive scope-of-practice bylaws allow NPs to perform these injections.
Although some NPs do not consider themselves involved in "cosmetic procedures", many do have daily encounters with patients seeking assistance with conditions they feel are important to their well-being, but are not medically necessary and not categorized as traditional cosmetic procedures. Patients present with acne and warts; acrochordons (skin tags); seborrheic keratosis; melasma (brown facial patches); liver spots (flat, brown patches on sun-exposed areas such as the dorsal surface of the hands, forearms or neck); vitiligo; stretch marks; keloids following invasive surgery; alopecia or generalized thinning at the top of the scalp; or bruising and purpura in elderly patients, due to aspirin use, warfarin therapy, and thinning skin.
Every healthcare practitioner will see patients who have had or may want cosmetic procedures, and today's NP, trained in the model of incorporating the whole person, is well situated to inform and educate patients on age-prevention techniques, improving health practices that increase confidence and self-esteem (ie. exercise, smoking cessation), and the rapidly evolving cosmetics field.
The skin is the largest organ of the body. Proper knowledge of the skin's structure helps practitioners understand how to maintain smoothness and suppleness and how dermal fillers can work properly. There are three main layers of skin: epidermis, dermis, and subcutaneous tissue (see Three-dimensional view of the skin). Although they work together, each is responsible for particular functions.
The top layer is the epidermis. It is the thinnest of the three layers and works as the main barrier to the body. This surface is subjected to daily exposure from the sun, weather, bacterial and viral infections, trauma, and the general stress of interacting with the environment. The epidermis contains melanin that defines skin color and sheds old keratin. It can become dry and scaly, and produce papules and macules or benign brown moles, red spots, or skin tags that patients seek to remedy whether by purchasing over-the-counter products or consulting a healthcare practitioner for advice.
The second layer is the dermis. Composed of blood vessels and nerves, it is mostly a sea of collagen, a durable protein that supports the epidermis. Collagen gives skin a smooth, supple, and elastic feel depending on the health, age, and thickness of the layer. The term "collagen" is used loosely, as there are nearly a dozen types of collagen in the dermal matrix, all working together to provide resilience and stability. The dermis is also the cornerstone of the cosmetic industry: manipulating the dermal layer is the key to younger-looking skin.
The final layer is the subcutaneous tissue, which stores fat. With age, however, its volume can decrease in the arms, legs, and face, while increasing in the abdomen in men, and in the thighs and buttocks in women. The classic treatment for fat deposits is often mechanical removal by liposuction or surgery by "tucks."
Any discussion of new research and trends in cosmetic dermatology must be preceded by an emphasis on preventing damage to the skin. The simplest and most well-documented practice is limiting the amount of sun exposure, as early research suggests that UVA and UVB may reduce production of collagen over time.2 The use of appropriate sunscreens, awareness of increased UV light in the late morning and afternoon hours, and lightweight clothing can dramatically lower the damage of skin over a patient's lifetime. Both inexpensive and effective, sunscreen also reduces photosensitivity issues with medications, pigment changes of mottling and patching, wrinkling, and skin cancer risk from prolonged UV light exposure. There are also many daily moisturizers that contain sunscreen that can delay lentigines and wrinkling. Patients should be advised to avoid tanning beds unless medically prescribed.
UVA exposure, which causes cancer and wrinkles (UVB causes sunburn), is sometimes ignored by manufacturers, and NPs must educate patients to seek out products that contain both UVA and UVB ratings. Also, most patients do no apply the sunscreen as thickly as it is applied in testing. The FDA is examining ways to implement stricter rules as well as implement a rating strategy for UVA on sunscreen products by the summer of 2011.
These fillers, or volumizers, are available as outpatient procedures and result in nearly immediate natural-appearing improvements. Some results can last up to 5 years. The products come in three broad categories: temporary fillers such as neurotoxins that act as muscle relaxants; human- and mammalian-derived collagens and hyaluronic acids; and semipermanent, collagen-stimulatory fillers such as calcium hydroxylapatite and poly-L-lactic acid (permanent fillers such as fat and silicone are beyond the scope of this discussion). A thorough knowledge of facial anatomy and an understanding of how to use the product are required when injecting dermal fillers (see Facial muscles).
Botulinum toxin product, a potent FDA-approved injectable neurotoxin, is used for treating frown lines in the forehead (frontalis muscles), vertical lines between the eyes (these look like the number "11" [procerus muscles]), and crow's feet (orbicularis oculi). OnabotulinumtoxinA (Botox, Botox Cosmetic) is a purified protein complex derived from the bacterium Clostridium botulinum that loosens and smooths muscles by blocking transmission of acetylcholine impulses. Results are seen in days. AbobotulinumtoxinA (Dysport) is also FDA approved and was released in 2009. While Botox is formulated with human albumin, Dysport contains lactose and albumin, and there are currently no published studies comparing the strength, time to onset, and longevity of effect between the two products.3 Recent concerns that long-term use of botulinum toxin may cause the neurotoxin to slip into the bloodstream or lymphatic system and move toward the brain have been proven in mice, but implications for human use are unknown.4
In addition, the FDA has required manufacturers of botulinum toxin to include a black box label with their product warning of a very rare complication of the use of the toxin. It appears that when botulinum toxin is used for illnesses that require high doses of the product for therapeutic levels, there is a possibility the toxin may spread beyond the injection site and cause neurological complications, which resulted in 16 deaths in 2009. This has not been noted a single time when used for cosmetic purposes, though adverse events occur when mixing different brands which may be manufactured to be dosed at different levels.
Collagen is plentiful in the dermis. UV light, aging, and sun exposure result in the production of collagenase, an enzyme that breaks down collagen. Injecting collagen, or "soft tissue augmentation," is a stopgap measure designed to reduce the loss of volume and enhance smoothness. Depending on the place and amount injected, the effects of collagen and hyaluronic acid can last from 3 months to a year. These products were designed for lip augmentation, scar treatment, fine and deep wrinkles, furrows, and volume replacement.
Due to allergic reactions to bovine products, many people prefer bioengineered human collagen, but the effects generally only last 3 months. Human-based collagen products (CosmoDerm and CosmoPlast), are cultured from bioengineered human skin and placed on special meshes in bioreactors where the mammalian cell cultures are grown.5 These products also contain lidocaine (Xylocaine) to reduce injection pain in sensitive areas and can be used safely in conjunction with hyaluronic acid, and can offer enhanced results. CosmoDerm and CosmoPlast are contraindicated in individuals with autoimmune disorders. The higher cost to produce these fillers results in markedly higher prices, but public acceptance and few adverse events make human collagen a good choice.6
Bovine-derived collagen (Zyderm I, Zyderm II, and Zyplast), is less expensive, widely used, and, since its introduction nearly 20 years ago, bovine collagen has proven effective. To detect possible allergic reactions, two skin tests are required before injection. Working on the same principle as a patch test, hypersensitive reactions occur in a small fraction of the population. Patients should be reassured that contamination is lessened as the collagen is collected from protected cattle herds.7
A hybrid of both purified bovine collagen and polymethylmethacrylate, Artefill is the first nonresorbable, lidocaine-aesthetic injectable for correction of nasolabial folds. Approved in late 2006, it is undergoing postmarketing safety studies.8 Artefill is both a dermal filler and a stimulant for collagen production. As the bovine collagen is absorbed, it is replaced by the new stimulated collagen. Its effects appear to last up to 5 years.
Hyaluronic acid is a naturally occurring polysaccharide that has the ability to bind with water up to 1,000 times its own volume. This allows the product to create volume in lips and around the eyes, fill in acne scars, and treat deep wrinkles that are resistant to other treatments.6 Hyaluronic acid is derived from avian or bacterial sources, and can be used for very fine lines as well as deep folds. It does not require allergy testing, nor is it associated with autoimmune disorders such as lupus or psoriasis. Adverse reactions are rare, and usually consist of temporary redness, swelling, itching, and tenderness at the site of injection, which resolve in a few days to weeks. Granulomatous formation is extremely unlikely.
The non-animal stabilized hyaluronic acid injectable gel, Restylane, has been leading the dermal filler category as far as sales since its introduction in 2003, and along with the hyaluronic acid gel, Juvederm, is preferred for fine lines and deep wrinkles.8 Research has demonstrated that in patients injected with Restylane, collagen synthesis was observed just 1 week later, and still seen 3 months later.9
Perlane, another hyaluronic acid filler, has a larger molecule than Restylane, and can easily fill deep wrinkles and folds. Perlane's larger gel particles offer enhanced volume and lifting power, ideal for wrinkle and fold correction in deeper layers of the skin. Results peak at 4 months, and touch-up work is recommended every 8 months. Additional hyaluronic acid fillers include Puragen, a non-animal-based hyaluronic acid gel, which is derived from bacteria; Hylaform and Hylaform Plus (made from the combs of roosters); and Captique, a plant-based filler. Prevelle Silk and Elevess also contain lidocaine in their formularies.
Additional fillers that are difficult to categorize are Dermalive, Dermadeep, and Fascian. The two complementary fillers, Dermalive and Dermadeep, are long-lasting, hyaluronic acid-based products combined with acrylic hydrogel. They are used in Europe and currently undergoing FDA trials for use in the United States. As the hyaluronic acid begins to steadily degrade, it is absorbed in the body, while the acrylic remains. Some have experienced 5 to 10 years of results with very little maintenance or reinjection. This thick gel has also been used for chin augmentation.
Fascian is a purified human connective tissue in liquid suspension. Grafts are obtained from cadavers, typically from the gastrocnemius fascia, then irradiated, processed, purified, and thickened with hyaluronic acid. It is FDA approved and subject to a highly regulated process. Although considered safe and hypoallergenic, the effects last for 3 to 12 months. There are also autologous preparations, such as isolagen, in which a patient's own cells are extracted, mixed with hyaluronic acid, and then reinjected. Isolagen, which is used in Europe but is currently not FDA approved, has completed phase III studies demonstrating safety and efficacy, with no serious adverse events, and 93% of patients note improvement at 6 months.10
Sculptra is an FDA-approved, collagen stimulator poly-L-lactic acid dermal filler that promotes tissue growth in HIV-positive patients who have lost facial fat. It is a synthetic polymer from the alpha-hydroxy acid family that has been used for centuries as a natural product from citrus fruit and is known for its exfoliative properties. It is biocompatible with humans and biodegradable over its 2-year life span as a filler.
The only FDA-approved calcium hydroxylapatite, Radiesse has a unique combination of naturally occurring chemicals present in the body. Unlike the concerns over botulinum toxin products, Radiesse does not migrate to other body systems or organs, and the calcium and phosphate ions suspended in the water-based gel eventually degrade and are absorbed by the body. The manufacturer claims that collagen production is stimulated at the time of delivery, and growth has been verified around the injection site. The effects last for 1 year.
Injections are generally made by five recognized methods: straightforward 90-degree depot or bolus injections; serial punctures of multiple drops placed along the length of a wrinkle or fold; cross-hatching, which treats a frown line from opposing sides; linear threading, in which the full length of the needle is inserted and the filler injected while pulling the needle backward so the filler is released; or fanning, which requires a single insertion while the filler is released by a pivot and swivel motion to the left and right.11 The NP should exercise a "treat, wait, and assess" approach to determine whether further injections are warranted.2
Manufacturers often state on their websites that the public should seek either a board-certified physician or NP who has undergone training for these procedures. The official position of the American Society for Dermatologic Surgery states that, "Under the appropriate circumstances, a physician may delegate certain procedures to certified or licensed allied health professionals," and "shall be physically present on-site, immediately available, and able to respond promptly to any question or problem that may occur while the procedure is being performed."12 All healthcare providers must seek out and receive extensive training by working in partnership with a practitioner experienced in these techniques and/or taking a certification course offered by the manufacturer. NPs also must understand and uphold their own state's scope of practice regulations.
Because of the pressures in American society to uphold a certain physical appearance in spite of the natural process of aging, NPs will encounter more and more patients who either wish to try dermal fillers or may already have experienced the procedure. At a cost of $500 to $1,000 per session, and often combined with a botulinum toxin product, the budget for cosmetics use can be significant to some consumers. NPs must assist patients in recognizing realistic personal goals and also remain knowledgeable regarding current products available.
1. The American Society for Aesthetic Plastic Surgery. Top 5 procedures: Surgical and nonsurgical. http://www.surgery.org/sites/default/files/2009Top5_Surg_NonSurg.pdf. [Context Link]
2. Fligiel SE, Varani J, Datta SC, et al. Collagen degradation in aged/photodamaged skin in vivo and after exposure to matrix metalloproteinase-1 in vitrol. J Invest Dermatol. 2003; 120(5):842-8. [Context Link]
3. Schlesinger J. A new form of botulinum toxin. Skin Aging. 2009;17(10):38-40. [Context Link]
4. Begley S. A new reason to frown: does Botox get into the brain? Troubling research contradicts earlier findings about the treatment. Newsweek. 2008. http://www.newsweek.com/id/131749. [Context Link]
5. BioNews Online. What is a bioreactor? 2008. http://www.bionewsonline.com/o/what_is_bioreactor.htm. [Context Link]
6. Baumann L. Dermal filling agents: making the right choice for your patient. Skin Aging 2007;15(3):38-44. [Context Link]
7. Sherman RN. Sculptra: the new three-dimensional filler. 2006;33(4):539-550. [Context Link]
8. Tierney RK. Pumping up the volume. MedEsthetics Magazine. 2008:27-32. http://www.michelegreenmd.com/index-4.html[Context Link]
9. Wang F, Garza LA, Kang S, et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol. 2007; 143(2):155-163. [Context Link]
10. Meyer E. Cosmetic dermatology update: highlights of recent news and trends. Isolagen therapy safe and effective treatment for skin quality and wrinkles. Skin Aging. 2008. http://www.skinandaging.com/content/cosmetic-dermatology-update-highlights-recen. [Context Link]
11. Michaels J, Comstock J. The advanced art of facial fillers. Skin Allergy News. 2008:S1-S8. [Context Link]
12. American Society for Dermatologic Surgery. Position Statement on Non-Physician Practice Of Medicine And Use Of Non-Physician Office Personnel.http://www.asds.net/PositionStatementonNonPhysicianPracticeOfMedicineAndUseOfNon. [Context Link]
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